Bilateral Orbital Abscesses After Strabismus Surgery.

Infectious orbital complications after strabismus surgery are rare. Their incidence is estimated to be 1 case per 1,100 surgeries and include preseptal cellulitis, orbital cellulitis, subconjunctival and sub-Tenon's abscesses, myositis, and endophthalmitis. This report describes the case of an otherwise healthy 3-year-old boy who underwent bilateral medial rectus recession and disinsertion of the inferior obliques. A few days after surgery, the patient presented with bilateral periorbital edema and inferotemporal chemosis. A series of CT scans with contrast revealed inferotemporal orbital collections OU. The patient immediately underwent transconjunctival drainage of fibrinous and seropurulent collections in the sub-Tenon's space and experienced rapid improvement a few days later. The patient is reported to be in stable condition in a follow-up examination performed more than a year after the reported events.

Bilateral internal carotid artery dissection presenting as isolated unilateral Horner syndrome.

A 52-year-old man developed a unilateral Horner syndrome following a skiing accident. He was otherwise asymptomatic. Neuroimaging with magnetic resonance revealed bilateral internal carotid artery dissections, and he was urgently treated with anticoagulation. Immediate neuroimaging should be performed in any patient with Horner syndrome following trauma, regardless of other symptoms or signs.

Smooth nylon foil (SupraFOIL) orbital implants in orbital fractures: a case series of 181 patients.

PURPOSE: 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. METHODS: 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. RESULTS: 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). CONCLUSIONS: 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.

Dacryoadenitis caused by methicillin-resistant Staphylococcus aureus.

A healthy 23-year-old man developed swelling of his left upper eyelid, conjunctival chemosis, and ocular motility restriction associated with epiphora and purulent discharge from the lacrimal ductules. Clinical examination, imaging, and culture results disclosed dacryoadenitis caused by community-acquired methicillin-resistant Staphylococcus aureus. To our knowledge, this is the first reported case of methicillin-resistant S. aureus-associated dacryoadenitis.

Use of porous polyethylene with embedded titanium in orbital reconstruction: a review of 106 patients.

PURPOSE: To evaluate our initial experience with a porous polyethylene implant with embedded titanium in orbital reconstruction. METHODS: 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. RESULTS: 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. CONCLUSIONS: 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.

Cicatricial ectropion associated with treatment of metastatic colorectal cancer with cetuximab.

Cetuximab is a monoclonal antibody that binds to the epidermal growth factor receptor (EGFR) of cancer cells expressing EGFR and prevents dimerization and downstream cell signaling pathways. It has been shown to prolong survival in patients with metastatic colorectal cancer. Cutaneous toxicity is relatively common because of the inhibition of EGFR of normal epidermal cells. We present a 49-year-old man with metastatic colon cancer who had development of periocular skin toxicity, madarosis, and cicatricial ectropion after the addition of weekly cetuximab infusions to his baseline chemotherapy. His findings resolved within weeks of the discontinuation of the drug. Cicatricial ectropion is a potential sequela of EGFR inhibition by cetuximab and can resolve without surgical intervention with the discontinuation of this drug.

New corticosteroid-eluting porous polyethylene implant for the management of lower eyelid retraction: a pilot study.

PURPOSE: Lower eyelid retraction after trauma presents a challenging management problem. We postulated that a porous polyethylene (pPE) eyelid spacer coated with a polyvinyl alcohol (PVA) and triamcinolone acetonide (TA) matrix could deliver corticosteroid locally over extended periods and modulate inflammation and scar formation. We designed a pPE corticosteroid-eluting implant and evaluated its characteristics in vitro and in vivo. METHODS: The release characteristics of pPE implants coated with a PVA/TA matrix of low, intermediate, and high doses of TA were studied in vitro. The implants were then placed in the posterior lamella of lower eyelids of Dutch Belted rabbits for 12 weeks. Clinical events were recorded and eyelids were examined for gross and histologic features, including capsular thickness and degree of vascularity, fibrovascular ingrowth, and inflammatory response. RESULTS: In vitro, implants coated with the intermediate and high doses of TA released the drug at a steady rate for at least 78 days. In rabbits, the PVA and PVA/TA coating prevented fibrovascular ingrowth, except where breaks in the PVA/TA coat were present. Implants with PVA/TA coating demonstrated less inflammation and capsule vascularity. An inverse correlation between TA dose and capsule thickness was noted. CONCLUSIONS: We describe a novel drug-release pPE eyelid implant. The corticosteroid-eluting implant demonstrated antiangiogenic and anti-inflammatory properties, which could prove beneficial in the treatment of lower eyelid retraction.

Anaesthetic abuse keratopathy as a manifestation of ocular Munchausen's syndrome.

Two patients, both with a history of major depressive disorder, presented with large bilateral corneal epithelial defects and ring-shaped stromal opacities. Both were initially treated unsuccessfully with topical antibiotic therapy for presumed infectious keratitis. One patient eventually admitted to topical anaesthetic abuse. In the second patient, signs of topical anaesthetic abuse and Munchausen's syndrome became evident. Cessation of anaesthetic use resulted in rapid resolution of the corneal epithelial defects in both patients. Anaesthetic abuse keratopathy is often a manifestation of underlying psychiatric illness, and psychiatric intervention is a very important part of management. To the authors' knowledge, this is the first report of ocular Munchausen's syndrome manifesting as anaesthetic abuse keratopathy.

Effect of 0.5% apraclonidine on ptosis in Horner syndrome.

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.

Resection of an orbital lymphangioma with the aid of an intralesional liquid polymer.

A 28-year-old man with long-standing right proptosis presented with an extensive multilobulated partially cystic orbital mass thought to be a lymphangioma. Because of concern that excision or debulking of the lesion was likely to be complicated by excessive bleeding, the lesion was injected with a mixture of ethiodized oil (Ethiodol) and cyanoacrylate glue under direct observation. The mixture caused the injected lobules to assume a firm, rubbery texture, allowing them to be excised without bleeding.

Features of the iridocorneal endothelial syndrome on confocal microscopy.

PURPOSE: To present a subtle case of iridocorneal endothelial (ICE) syndrome and discuss the utility of in vivo confocal microscopy in the evaluation of this disorder. Previous reports of the confocal microscopic features of ICE syndrome are reviewed. METHODS: A 32-year-old man presented with decreased vision and halos. Slit-lamp biomicroscopy and in vivo confocal microscopy were used to evaluate the etiology of his complaints. Clinical photographs and confocal micrographs were analyzed. RESULTS: In vivo confocal microscopy revealed marked asymmetry between the right and left corneal endothelial layers with pleomorphic epithelioid cells on the right, some with hyperreflective nuclei. A transition between cells with uniform appearance and dark nuclei and a highly irregular cellular arrangement with hyperreflective nuclei was present. CONCLUSIONS: This report supports the clinical utility of in vivo confocal microscopy in the evaluation of ICE syndrome. It demonstrates that the histopathologic features of ICE syndrome on scanning electron microscopy may be shown clinically using high-resolution confocal microscopy.

Immunotactoid keratopathy: a clinicopathologic case report and a review of reports of corneal involvement in systemic paraproteinemias.

Corneal deposits in association with paraproteinemias have been well described in the ophthalmic literature. Recent reports in the renal literature have described immunotactoid deposition associated with glomerulopathy-organized microtubular deposits of IgGkappa that measured 32-50 nm in diameter on renal biopsies. We present a case of corneal immunotactoid deposition in the setting of chronic lymphocytic leukemia and review previous reports of corneal deposition in the setting of systemic paraproteinemia, highlighting the etiology, differential diagnosis, prognosis, and treatment of corneal involvement. We propose the use of the term immunotactoid keratopathy to describe corneal IgGkappa deposits appearing as tubular, electron-dense, crystalloid deposits with a central lucent core on electron microscopy and suggest that these patients undergo directed systemic workup to evaluate for potential etiologies of their systemic paraproteinemia. To illustrate the spectrum of paraprotein deposition in the cornea, and to emphasize the importance of ophthalmic evaluation in the setting of systemic paraproteinemias, we include a case of a 44-year-old man with immunoprotein corneal deposition who was subsequently diagnosed with multiple myeloma.

Butterfly-shaped pattern dystrophy: a genetic, clinical, and histopathological report.

OBJECTIVES: To identify the disease-causing mutation in a large family segregating dominantly inherited butterfly-shaped pattern dystrophy (BPD) and to describe the microscopic pathological changes observed in a member of this family. METHODS: Seventeen individuals at risk for dominantly inherited BPD in a family were examined and blood samples obtained. Linkage analysis and mutation screening of the human retinal degeneration slow (RDS)/peripherin locus were performed. Light and electron microscopic examinations were performed on 1 postmortem eye of 1 affected individual. RESULTS: Four individuals demonstrated macular degenerative changes with diminished visual acuity, and 3 others exhibited early signs of atrophy without visual deficits. Microscopic examination of the left eye of 1 patient revealed an area of total loss of the retinal pigment epithelium (RPE) and photoreceptor cell layer with intact choriocapillaris and lipofuscin-containing cells in the subretinal space. Outside the area of RPE atrophy, the RPE was greatly distended by lipofuscin. The disease locus in this family was mapped to 6p21.2, the region of the RDS/peripherin gene. Further analysis identified a G-->A change at nucleotide position 637 of RDS/peripherin, predicting a novel Cys213Tyr substitution in all affected members of the family. CONCLUSIONS: This study describes a new RDS/peripherin mutation for BPD and provides the first combined genetic-pathological study of this condition, to our knowledge. CLINICAL RELEVANCE: Accumulation of lipofuscin in RPE is a prominent feature of several retinal disorders, including age-related macular degeneration. Further elucidation of the cellular and molecular mechanism of BPD may provide insight into pathogenesis and lead to novel treatment approaches for this and other macular degenerations.