Social implications of blepharoptosis and dermatochalasis.

PURPOSE: To investigate the social implications of blepharoptosis and dermatochalasis. METHODS: Two hundred ten individuals rated whole-face photographs of a series of patients based on 11 different personal characteristics: intelligence, threat, friendliness, health, trustworthiness, hard work, mental illness, financial success, attractiveness, alcoholism, and happiness. Preoperative and postoperative photographs of both male and female patients with bilateral blepharoptosis and/or dematochalasis were used. The paired t test was used to compare preoperative versus postoperative ratings on the 11 characteristics. RESULTS: The preoperative photographs were rated more negatively than were the postoperative photographs (p < 0.01) on all 11 characteristics for both male and female patients by the 210 study subjects. CONCLUSIONS: Members of our society view individuals with blepharoptosis and dermatochalasis negatively. These social attitudes may lead to unjust bias toward affected patients, and surgical correction probably provides benefits beyond improved visual function.

Post hoc, ergo propter hoc.

Three cases are described in which patients sought damages for retinal detachments that followed minor trauma. In fact, the traumatic incidents were not responsible for the detachments. Criteria for diagnosing traumatic retinal detachments are summarized, and ophthalmologists and attorneys are cautioned to be wary of post hoc reasoning.

Psychosocial implications of blepharoptosis and dermatochalasis.

PURPOSE: To investigate, for the first time, the psychosocial implications of blepharoptosis and dermatochalasis. METHODS: Two hundred ten individuals rated whole-face photographs of a series of patients on the basis of 11 different personal characteristics: intelligence, throat, friendliness, health, trustworthiness, hard work, mental illness, financial success, attractiveness, alcoholism, and happiness. Preoperative and postoperative photographs of both male and female patients with bilateral blepharoptosis and/or dermatochalasis were used. The paired t test was used to compare preoperative and postoperative ratings on the 11 characteristics. RESULTS: The preoperative photographs were rated more negatively than the postoperative photographs (P < .01-P < .001) on all 11 characteristics for both male and female patients by the 210 study subjects. CONCLUSIONS: Members of society seem to view individuals with blepharoptosis and dermatochalasis negatively. These psychosocial attitudes may lead to unjust bias toward affected patients, and surgical correction likely provides benefits beyond improved visual function.

Mechanisms of orbital floor fractures: a clinical, experimental, and theoretical study.

PURPOSE: The purpose of this study was to investigate the two accepted mechanisms of the orbital blowout fracture (the hydraulic and the buckling theories) from a clinical, experimental, and theoretical standpoint. METHODS: Clinical cases in which blowout fractures resulted from both a pure hydraulic mechanism and a pure buckling mechanism are presented. Twenty-one intact orbital floors were obtained from human cadavers. A metal rod was dropped, experimentally, onto each specimen until a fracture was produced, and the energy required in each instance was calculated. A biomathematical model of the human bony orbit, depicted as a thin-walled truncated conical shell, was devised. Two previously published (by the National Aeronautics and Space Administration) theoretical structural engineering formulas for the fracture of thin-walled truncated conical shells were used to predict the energy required to fracture the bone of the orbital floor via the hydraulic and buckling mechanisms. RESULTS: Experimentally, the mean energy required to fracture the bone of the human cadaver orbital floor directly was 78 millijoules (mJ) (range, 29-127 mJ). Using the engineering formula for the hydraulic theory, the predicted theoretical energy is 71 mJ (range, 38-120 mJ); for the buckling theory, the predicted theoretical energy is 68 mJ (range, 40-106 mJ). CONCLUSION: Through this study, we have experimentally determined the amount of energy required to fracture the bone of the human orbital floor directly and have provided support for each mechanism of the orbital blowout fracture from a clinical and theoretical basis.

Measure for measure.

Shakespeare's play Measure for Measure colorfully illustrates a concept that is relevant to the testimonies given by the medical expert witness in the courtroom. The expert should not ask the jury to hold the defendant physician to a higher standard than that actually practiced by an acceptable reasonable minority of the defendant's peers under similar circumstances. Two cases are presented.

Ocular explosions from periocular anesthetic injections: a clinical, histopathologic, experimental, and biophysical study.

OBJECTIVES: An increasing number of cases are being recognized in which a periocular anesthetic for cataract surgery has been inadvertently injected directly into the globe under high pressure until the globe ruptures or "explodes." The objectives of the current study were to (1) analyze this injury clinically and histopathologically through a series of seven case reports; (2) reproduce the injury experimentally in human eyebank eyes, live anesthetized rabbit eyes, and human cadaveric eyes; (3) investigate the biophysical basis of the injury; and (4) outline recommendations to help decrease the risk of ocular rupture with periocular injections. DESIGNS/PARTICIPANTS: Clinical, histopathologic, experimental animal, autopsy eye, and theoretical biophysical study. METHODS: The clinical and histopathologic findings of the patients' eyes were documented. Human eyebank eyes, live anesthetized rabbit eyes, and human cadaveric eyes were exploded via direct intraocular saline injection. The laws of Bernoulli, LaPlace, Friedenwald, and Pascal were used to investigate theoretically the biophysics of the injury. RESULTS: The findings of anterior and posterior scleral rupture, retinal detachment, vitreous hemorrhage, and lens extrusion were observed clinically and experimentally. In some clinical and experimental cases, the anterior segment appeared entirely normal despite a posterior rupture. The surgeon proceeded with and completed the cataract surgery in two of the seven clinical cases without knowledge of the rupture. The pressure required to produce such an injury is in the range of 2800 to 6400 mmHg, and this pressure is more easily attained with a 3-ml syringe than with a 12-ml syringe. CONCLUSIONS: Explosion of an eyeball during the injection of anesthesia for ocular surgery is a devastating injury that may go unrecognized. The probability of an ocular explosion can be minimized by (1) the use of a blunt needle and a 12-ml syringe, (2) aspirating the plunger and wiggling the syringe before injection, (3) discontinuing the injection if corneal edema or resistance to injection is noted, and (4) inspecting the globe for evidence of intraocular injection before ocular massage or placement of a Honan balloon. On recognition of an ocular explosion, immediate referral to and intervention by a vitreoretinal surgeon is optimal.

Gallium scanning in the diagnosis and management of orbital lymphoma: a case report.

PURPOSE: To illustrate the utility of gallium scintigraphy in the diagnosis and management of orbital lymphoma. METHODS: A patient with an orbital lymphoma is reported. The results of the computed tomography scan and gallium scan are reviewed. RESULTS: Although the orbital lymphoma was readily visible on the gallium scan, it was poorly visualized on the computed tomography scan, which was interpreted as normal. CONCLUSION: Gallium scanning is a valuable adjunct in the diagnosis and management of orbital and systemic lymphoma.

Unusual orbital foreign bodies.

PURPOSE: To describe the clinical features of patients with unusual orbital foreign bodies. METHODS: The clinical histories, preoperative photographs, imaging studies, and surgical pathologic findings of five patients with unusual orbital foreign bodies are presented. Additionally, published reports pertaining to similar cases were reviewed. RESULTS: The five patients treated by the authors had good outcomes. CONCLUSIONS: An orbital foreign body may be overlooked because a small penetrating wound may be accompanied by minimal or no signs of inflammation early in the clinical course. A careful history and physical examination, imaging studies, and a strong suspicion are helpful for establishing the diagnosis of an orbital foreign body.

Mechanisms of orbital floor fractures: a clinical, experimental, and theoretical study.

PURPOSE: The purpose of this study was to investigate the two accepted mechanisms of the orbital blow-out fracture (the hydraulic and the buckling theories) from a clinical, experimental, and theoretical standpoint. METHODS: Clinical cases in which blow-out fractures resulted from both a pure hydraulic mechanism and a pure buckling mechanism are presented. Twenty-one intact orbital floors were obtained from human cadavers. A metal rod was dropped, experimentally, onto each specimen until a fracture was produced, and the energy required in each instance was calculated. A biomathematical model of the human bony orbit, depicted as a thin-walled truncated conical shell, was devised. Two previously published (by the National Aeronautics Space Administration) theoretical structural engineering formulas for the fracture of thin-walled truncated conical shells were used to predict the energy required to fracture the bone of the orbital floor via the hydraulic and buckling mechanisms. RESULTS: Experimentally, the mean energy required to fracture the bone of the human cadaver orbital floor directly was 78 millijoules (mj) (range, 29-127 mj). Using the engineering formula for the hydraulic theory, the predicted theoretical energy is 71 mj (range, 38-120 mj); for the buckling theory, the predicted theoretical energy is 68 mj (range, 40-106 mj). CONCLUSION: Through this study, we have experimentally determined the amount of energy required to fracture the bone of the human orbital floor directly and have provided support for each mechanism of the orbital blow-out fracture from a clinical and theoretical basis.

Coexistence of 3 tumors of neural crest origin: neurofibroma, meningioma, and uveal malignant melanoma.

OBJECTIVE: To describe the clinical findings in a patient who developed a neurofibroma, meningioma, and choroidal melanoma. METHODS: Clinical and histopathological findings of the case are reviewed and presented. RESULTS: The patient had a right superolateral periorbital neurofibroma, a right sphenoid wing meningioma, and a left choroidal juxtapapillary malignant melanoma. All 3 tumors are derived from neural crest cells. CONCLUSIONS: To our knowledge, this is the first report of a patient with this combination of 3 neural crest-derived tumors. This case is most appropriately classified as a complex neurocristopathy, a disorder involving the aberrant and pathological proliferation of multiple tissues derived from neural crest cells.

Was Dom Perignon really blind?

Many sources perpetuate the tripartite myth that Dom Perignon was the blind inventor of champagne, whose senses of taste and smell were enhanced by his loss of vision. This myth, however, is seemingly contradicted by historical fact. Not only do ancient references suggest that sparkling wine existed long before Perignon's time, but the making of champagne was a scientific process that required careful measuring, weighing, and record keeping, and it is unlikely that Perignon was blind when he was perfecting champagne. While the truth regarding Dom Perignon's blindness has disappeared during the more than two and a half centuries since his death, it is interesting to speculate why he may have lost vision at some stage of life. A brief history of Perignon's discovery of the secret of champagne and the blindness myth is traced, and a differential diagnosis is given, including cataracts, uncorrected refractive error, alcohol toxicity, and champagne-related ocular/cerebral trauma.

Cystoid macular edema and anterior uveitis associated with latanoprost use. Experience and incidence in a retrospective review of 94 patients.

OBJECTIVE: This study aimed to investigate the incidence of cystoid macular edema and anterior uveitis associated with the use of latanoprost. DESIGN: A retrospective review of patients treated with latanoprost in the authors' practice between September 1, 1996, and August 1, 1997, was performed. PARTICIPANTS: Ninety-four patients and 163 eyes were studied. INTERVENTION: Patients presenting with signs and symptoms of ocular inflammation while receiving latanoprost were noted, and their response to the discontinuation of the drug was recorded. MAIN OUTCOME MEASURES: The presence and degree of anterior uveitis and cystoid macular edema were measured. RESULTS: Six (6.4%) of 94 patients (8 [4.9%] of 163 eyes) had anterior uveitis develop, and 2 (2.1%) of 94 patients (2 [1.2%] of 163 eyes) had cystoid macular edema develop while being treated with latanoprost. CONCLUSION: Although latanoprost is an effective ocular-hypotensive agent, the authors' experience with the drug has shown a significant incidence of anterior uveitis and cystoid macular edema. To the authors' knowledge, this is the first study to report the incidence of both cystoid macular edema and anterior uveitis associated with latanoprost therapy. Treating physicians should be aware of these potential complicating side effects of latanoprost.

Ocular explosion during cataract surgery: a clinical, histopathological, experimental, and biophysical study.

INTRODUCTION: An increasing number of cases are being recognized in which a peribulbar anesthetic for cataract surgery has been inadvertently injected directly into the globe under high pressure until the globe ruptures or explodes. We reviewed the records of 6 such cases (one of which was reported previously by us), and one additional case has been reported in the literature. Surprisingly, 2 of these 7 cases went unrecognized at the time, and the surgeons proceeded with the cataract operation; all of the patients ultimately developed severe visual loss and/or loss of the eye. OBJECTIVES: To reproduce this eye explosion in a live anesthetized rabbit model and to perform a clinical, histopathological, experimental, biophysical, and mathematical analysis of this injury. METHODS: Eyes of live anesthetized rabbits were ruptured by means of the injection of saline directly into the globe under high pressure. The clinical and pathological findings of the ruptured human and animal eyes were documented photographically and/or histopathologically. An experimental, biophysical, and mathematical analysis of the pressures and forces required to rupture the globe via direct injection using human cadavers, human eye-bank eyes, and classic physics and ophthalmic formulas was performed. The laws of Bernoulli, LaPlace, Friedenwald, and Pascal were applied to the theoretical and experimental models of this phenomenon. RESULTS: The clinical and pathological findings of scleral rupture, retinal detachment, vitreous hemorrhage, and lens extrusion were observed. In the exploded human and rabbit eyes, the scleral ruptures appeared at the equator, the limbal area, or the posterior pole. In 2 of the 7 human eyes, the anterior segments appeared entirely normal despite the rupture, and cataract surgery was completed; surgery was canceled in the other 4 cases. In 4 of the 5 injected and ruptured rabbit eyes, the anterior segments appeared essentially normal. The experiments with human eye-bank eyes and the theoretical analyses of this entity show that the pressure required to produce such an injury is much more easily obtained with a 3- or 5-mL syringe than with a syringe 10 mL or larger. CONCLUSIONS: Explosion of an eyeball during the injection of anesthesia for ocular surgery is a devastating injury that may go unrecognized. The probability of an ocular explosion can be minimized by careful use of a syringe 10 mL or larger with a blunt needle, by discontinuing the injection if resistance is met, and by inspecting the globe prior to ocular massage or placement of a Honan balloon. When ocular explosion occurs, immediate referral to and intervention by a vitreoretinal surgeon is optimal. Practicing ophthalmologists should be aware of this blinding but preventable complication of ocular surgery.

Ocular and orbital trauma from water balloon slingshots. A clinical, epidemiologic, and experimental study.

PURPOSE: The authors report the findings of 17 patients with ophthalmic injuries produced by launched water balloons; they determine water balloon kinetic energies in experimental and theoretical studies. METHODS: Six case summaries are presented; one case report was retrieved from the literature; ten injuries were reported to the Consumer Product Safety Commission. Energies were determined by field trials and calculations. RESULTS: Injuries included periorbital edema and ecchymoses, orbital contusions and hematomas, maxillary sinus hematomas, facial hypesthesia, eyelid lacerations, subconjunctival hemorrhages, corneal edema and abrasions, hyphemas, traumatic iritis, iris sphincter ruptures, iris atrophy, angle recession, iridodialysis, traumatic cataract, vitreous hemorrhages, retinal hemorrhages, macular hole formation, optic atrophy, and bony orbital wall fractures. Epidemiologic analysis revealed that children and young adults, more often males, were injured, most commonly in the warm weather months. In field trials, maximum water balloon velocities ranged from 38 to 41 m/sec (85-92 mph) with kinetic energies from 176 to 245 joules; by calculation, maximum velocities ranged from 42 to 54 m/sec (95-121 mph) with kinetic energies from 141 to 232 joules. In a field demonstration, a slingshot-launched water balloon exploded a watermelon. CONCLUSION: Energies are comparable to or greater than those experienced with a variety of common objects, including some rifle bullets that are known to cause serious ophthalmic injuries. These energies are far in excess of those required to perforate a cornea, rupture a globe, or fracture the bony orbit. This study demonstrates the serious and potentially vision- and life-threatening injuries inflicted by these "toys."

Ocular explosion after peribulbar anesthesia: case report and experimental study.

PURPOSE: A peribulbar anesthetic injection for cataract surgery produced a 10.5-mm scleral laceration and lens extrusion. This study sought to recreate this unfortunate clinical situation. METHODS: Twenty-one human eye bank eyes were ruptured by intraocular injection of saline through Atkinson needles. The hydrostatic pressure required for globe rupture was measured by three different techniques in seven globes. RESULTS: Forty-eight percent of the scleral lacerations were equatorial and 52% were perilimbal. Lens extrusion occurred with three of the perilimbal lacerations. Rupture pressures by each technique averaged 3065, 4972, and 5648 mmHg. CONCLUSION: Peribulbar injection can produce inadvertent ocular explosion.

Ocular and orbital trauma from water balloon slingshots: a clinical, epidemiological, experimental, and theoretical study.

PURPOSE: To report the clinical findings of 17 patients with ocular/orbital injuries produced by launched water balloons; to determine water balloon kinetic energies in experimental and theoretical studies. METHODS: Six case histories are presented, 1 case was retrieved from the medical literature, and 10 cases were reported to the National Injury Information Clearinghouse of the United States Consumer Product Safety Commission. The energies were determined by field trials and calculations. RESULTS: Injuries included orbital contusions and hematomas, facial hypesthesia, eyelid lacerations, subconjunctival hemorrhages, corneal edema and abrasion, hyphemas, traumatic iritis, iris sphincter ruptures, iris atrophy, angle recession, iridodialyses, traumatic cataract, vitreous hemorrhages, retinal hemorrhages, macular hole formation, optic atrophy, and bony orbital wall fractures. Epidemiological analysis revealed that children and young adults, more often males, were injured, most commonly in the warm weather months (May through September). In field trials, maximum water balloon velocities ranged from 38 to 41 m/sec (85 to 92 mph) with kinetic energies from 176 to 245 J; by calculation, maximum velocities ranged from 42 to 54 m/sec (95 to 121 mph) with kinetic energies from 141 to 232 J. In a field demonstration a 300-g water balloon launched horizontally from a distance of 20 ft exploded a 12-kg watermelon. Classic physics calculations are presented to explain the complex bio-mechanical interactions between the water balloon and the eye. CONCLUSION: Kinetic energies of launched water balloons are comparable to or greater than kinetic energies experienced with a variety of common objects, including file bullets, which are well known to cause serious ocular and orbital injuries. In addition, these energies are far in excess of those required to perforate a cornea (0.7 to 1.7 J), rupture a globe (1 to 5.3 J), or fracture the bony orbit (1.8 to 14.7 j). Thus, this study demonstrates the serious and potentially vision- and life-threatening injuries inflicted by these "toys."