Systemic fat and thrombus embolization in patients undergoing total knee arthroplasty with regional heparinization.

A double-blind, randomized, controlled study was undertaken to determine if a technique of intraoperative anticoagulation would decrease the incidence or severity of venous embolization after tourniquet release during total knee arthroplasty. Sixty-six patients were randomized to receive either the heparin or placebo treatment. Transesophageal echocardiography was performed before and after tourniquet release to detect embolic material in the right atrium. Transient opacification of the right atrium was observed in all patients within the first 30 seconds after tourniquet release. Regional limb heparinization is not effective in reducing the intensity of right atrium opacification because much of the echogenic material was composed of fat rather than thrombus.

Unilateral proptosis in an immunocompetent man as the initial clinical manifestation of systemic Hodgkin disease.

OBJECTIVE: Orbital involvement in Hodgkin disease (HD) is rare. Previously reported cases of HD in patients without the acquired immunodeficiency syndrome have been diagnosed late in the course of established systemic disease. The authors describe an immunocompetent man with orbital infiltration as the initial manifestation of systemic HD. DESIGN: Case report. PARTICIPANTS: A 47-year-old man with acute progressive, painless proptosis of the left eye is described. INTERVENTION: A well-defined, homogeneous soft tissue mass of the superior left orbit was evident on computed tomography, and an incisional biopsy of the nontender mass was performed. RESULTS: The histopathologic findings were characteristic of HD. Systemic investigations showed clinical stage 3A HD. Ten months after completion of hybrid chemotherapy, the patient remained in complete remission from his HD. CONCLUSION: Hodgkin disease presenting initially in the orbit of a patient with the acquired immunodeficiency syndrome has been described previously. The patient presented in this report is the first case of HD in the recent English literature with the initial manifestation in the orbit of an otherwise immunocompetent patient.

Transcanalicular neodymium: YAG laser for revision of dacryocystorhinostomy.

BACKGROUND: Laser-assisted dacryocystorhinostomy (DCR) has failed to match the success rates of external DCR. It has been suggested that this technology may be best suited for revision of failed DCR cases. The authors prospectively evaluated the efficacy of transcanalicular laser-assisted revision DCR (TCLARDCR). METHODS: A neodymium:YAG (Nd:YAG) laser was used for transcanalicular revision of 24 failed DCRs. Failure had followed one (n = 15), two (n = 7), or three (n = 2) previous external DCRs. RESULTS: Mean duration of the surgery was 78.2 minutes. Success was achieved in 11 cases (46%; mean follow-up, 20 months). There was no correlation between early loss of stents and failure. Three cases had partial relief of symptoms. Three of the failures unsuccessfully underwent further TCLARDCR. CONCLUSIONS: The authors' success rate of 46% with TCLARDCR compares poorly with the 85% success for external revision DCR. With TCLARDCR, specific anomalies like the sump syndrome cannot be addressed adequately. There is a theoretical risk of canalicular injury. Laser lacrimal surgery also is equipment dependent and more costly than external DCR. The TCLARDCR cannot be recommended for revision DCR using the Nd:YAG laser (Lasersonics, Milpitas, CA).

Management of postblepharoplasty lower eyelid retraction with hard palate grafts and lateral tarsal strip.

Lower eyelid malposition is the most common long-term complication following transcutaneous lower eyelid blepharoplasty. The malposition may include rounding of the lateral canthal angle, lower eyelid retraction with inferior scleral show, or frank ectropion. The result is cosmetically unacceptable and may be associated with tearing, irritation, and other exposure keratitis symptoms. Multiple factors, including lower eyelid laxity, shortage of skin, and scarring of the middle lamella, may be responsible for this malposition. A systematic examination of the lower eyelid, as presented, helps to assess the degree to which each of these factors is responsible for the malposition. Patients with the most severe degree of lower eyelid malposition generally have middle lamella scarring. If this abnormality is not addressed, lower eyelid procedures aimed at correcting the malposition are doomed to failure. In the presence of significant middle lamella scarring, a spacer is required to provide vertical height and stiffness to support the lower eyelid following release of the cicatrix. A systematic approach aimed at addressing the underlying abnormalities was developed. In patients with significant middle lamella scarring, hard palate mucosa grafts were used as spacers in 29 eyelids (17 patients). A lateral canthotomy and transconjunctival incision allow access to the scarring in the lower eyelid retractors and septum. After careful release of all cicatrix, a hard palate mucosa graft is inserted between the lower border of the tarsal plate and the recessed conjunctiva, lower eyelid retractors, and septum. Horizontal lower eyelid laxity, when present, is corrected by performing a lateral tarsal strip. Most patients do not have a true deficiency of the anterior lamella (skin and orbicularis oculi muscle). When a moderate amount of anterior lamella deficiency is present with significant scarring of the middle lamella, the technique we describe allows correction of the lower eyelid malposition without a skin graft. After a follow-up interval of 6 to 30 months (mean 14 months), excellent results were obtained in all eyelids. Complications included corneal abrasions in two eyes before routine use of bandage cornea contact lenses at the end of surgery and a secondary bleed from the roof of the mouth in one patient. Palate mucosa closely resembles tarsus and provides excellent vertical support to the eyelid. It is stiff enough to maintain eyelid contour without causing a cosmetically unacceptable bump. Tissue can be obtained with ease. The technique, as described, addresses the underlying causes of lower eyelid malposition and gives excellent functional and cosmetic results.

Use of hard palate grafts for treatment of postsurgical lower eyelid retraction: a technical overview.

Lower eyelid retraction occasionally occurs following the repair of fractures involving the orbital rims, orbital floor, or complex zygomatic maxillary complex fractures. The surgical repair of these scarred eyelids has been historically difficult. The authors have utilized the principle of releasing the scar tissue and attempting to reposition the eyelid in its normal anatomic position by employing a hard palate mucosal graft spacer to correct the eyelid malposition. In this article, the authors discuss the excellent success they have experienced utilizing hard palate autologous grafts as spacers performing revision of scarred contracted lower eyelid retractors and tightening of the lateral canthal tendon complex. Adherence to the principles delineated in the article can yield excellent functional and cosmetic results.

Orbital infections in patients with human immunodeficiency virus infection.

BACKGROUND: Opportunistic infections frequently involve the anterior and posterior segments of the eye but rarely occur in the orbit in patients with human immunodeficiency virus (HIV) infection. The authors managed eight patients with HIV and unilateral orbital infections who presented between July 1988 and March 1995. METHODS: Records of the patients were reviewed. A literature review of orbital infections in patients infected with HIV also was conducted. RESULTS: There were five men and three women, with a mean age of 33.8 years. The mean CD-4 cell count from five of the eight patients was 18.4 cells/mm3. Invasive aspergillosis was the most common orbital infection occurring in four patients, all of whom had contiguous sinus involvement and intracranial extension. Orbital cellulitis with subperiosteal abscesses secondary to ethmoiditis caused by Propionibacterium acnes and Pseudomonas aeruginosa developed in two patients. Orbital cellulitis and panophthalmitis secondary to Staphylococcus aureus endogenous endophthalmitis developed in one patient, and one patient had presumed syphilitic optic neuritis, orbital periostitis, and necrotizing vasculitis. Five patients had permanent visual loss, including four who had loss of light perception. Four patients died of orbital diseases within 1 year of presentation, and three deaths were attributed to intracranial spread of Aspergillus fumigatus. Other organisms reported in the literature that caused orbital infections in patients with HIV include Rhizopus arrhizus, Toxoplasma gondii, and Pneumocystis carinii. CONCLUSION: Opportunistic infections of the orbit from bacterial, fungal, and parasitic organisms should be recognized as a serious complication of systemic HIV infection and are associated with a high ocular morbidity and mortality rate.

Angiocentric T-cell lymphoma presenting with multiple cranial nerve palsies and retrobulbar optic neuropathy.

Angiocentric T-cell lymphoma (lymphomatoid granulomatosis) may present with prominent central nervous system (CNS) findings with variable radiographic features. We describe a patient who presented with multiple cranial nerve palsies involving the left optic nerve, left facial nerve, left ocular motor nerves, and bilateral acoustic nerves. Enhancement of the right temporal meninges and a cavernous sinus mass were noted on magnetic resonance (MR) scan. A right temporal craniectomy and meningeal biopsy were performed. Meningeal biopsy revealed atypical angiocentric granulomatous lymphoid infiltrates without associated necrosis, giant cells, or granuloma formation. Morphologic and T-cell, receptor gene rearrangement findings were diagnostic of an angiocentric T-cell lymphoma. Retrobulbar optic neuropathy and multiple cranial nerve palsies may be the presenting features of angiocentric T-cell lymphoma. The neurologic and unique radiographic changes in our case expand the previously reported findings in CNS angiocentric T-cell lymphoma.

Low flow dural arteriovenous shunt: another cause of "sinister" Tolosa-Hunt syndrome.

A 73-year-old man developed acute, painful, ophthalmoplegia. The pain improved with oral steroids and a diagnosis of Tolosa-Hunt syndrome was made. Review of his angiogram revealed a low flow dural arteriovenous shunt that drained posteriorly. Dural arteriovenous shunts may thus be another cause of "sinister" Tolosa-Hunt syndrome.

Embryonal rhabdomyosarcoma of the orbit in a 35-year-old man.

A 35-year-old man had rapidly progressive proptosis of the right eye with associated chemosis over a period of several weeks. Computed tomography demonstrated a solid extraconal mass in the inferior anterior right orbit. Pathologic examination revealed the lesion to be an embryonal rhabdomyosarcoma. Consistent with the diagnosis, immunohistochemical assays demonstrated positive staining with myoglobin, desmin, and muscle-specific actin. The lesion grew rapidly and was further surgically excised. Subsequently, treatment with radiation and chemotherapy was initiated. Primary embryonal rhabdomyosarcoma of the orbit is an extremely rare tumor in adults, and, to our knowledge, this patient represents the oldest individual reported to have developed such a tumor, as documented by immunohistochemical analysis.

Whitnall's sling with superior tarsectomy for the correction of severe unilateral blepharoptosis.

The management of severe unilateral blepharoptosis is problematic. In the presence of poor levator function, conventional surgical techniques frequently do not adequately elevate a ptotic eyelid. From May 1988 through July 1991, we used 4- to 5-mm external resections of the superior tarsus in conjunction with a maximal aponeurectomy (Whitnall's sling procedure) to augment blepharoptosis correction in selected cases of severe unilateral blepharoptosis. Seventeen (68%) of 25 patients with poor levator function blepharoptosis who underwent this new surgical procedure achieved a lid height within 1 mm of the opposite lid with good or excellent ocular function, cosmesis, and eyelid crease formation. Mild to moderate degrees of exposure keratopathy developed early in the postoperative period in all patients. This exposure keratopathy ultimately resolved in most patients. Superior tarsectomy safely augments the blepharoptosis correction of a Whitnall sling procedure in severe blepharoptosis, improving the results of aponeurotic surgery in patients with severe unilateral blepharoptosis.

Primary T-cell immunoblastic lymphoma of the orbit in a pediatric patient.

BACKGROUND: The authors report a case of an 8-year-old pediatric patient with a 2-week history of painless periorbital swelling unresponsive to antibiotic treatment. METHODS: Computed tomography (CT) showed a large, lateral, anterior left orbital soft tissue mass with bony erosion into the anterior cranial fossa through the roof of the orbit laterally. Surgical exploration showed a hard white mass that had eroded through the roof of the left orbit and into the anterior cranial fossa, with herniation of the brain and associated dura through the defect. Results of a complete evaluation of the child for systemic lymphoma, including a lumbar puncture, chest x-ray, bone scan, bone marrow aspirate, and chest/abdomen CT, were negative. RESULTS: Results of histopathologic and immuno-histochemical evaluation showed a primary orbital T-cell immunoblastic lymphoma. The patient was treated with intrathecal ara-C (Cytosar-U) and methotrexate, 16.2 Gy of whole brain irradiation, and a chemotherapeutic protocol consisting of cyclophosphamide (Cytoxin), vincristine (Oncovin), methotrexate, daunomycin, and prednisone. The patient remains free of lymphoma 33 months after diagnosis, with 20/20 visual acuity in both eyes. CONCLUSION: The authors believe that this is the youngest documented case of a primary T-cell immunoblastic lymphoma of the orbit.

Capnocytophaga endophthalmitis.

PURPOSE: This article presents three patients with endophthalmitis associated with infection with Capnocytophaga species. METHODS: The medical records of three patients with culture-positive Capnocytophaga endophthalmitis were reviewed. A panel of isolates of Capnocytophaga were then tested for sensitivity to third-generation cephalosporins. RESULTS: Endophthalmitis with Capnocytophaga species developed in three patients. Infection in the setting of sepsis developed in one patient. Two other patients, one with a penetrating injury and another with keratitis in association with a corneal graft, developed mixed infection with Capnocytophaga being the predominant infecting organism by culture. Two patients recovered vision with clearance of the infection. The third patient underwent enucleation. Capnocytophaga was found to be sensitive to several of the third-generation cephalosporins. To the best of the authors' knowledge, these are the first reported cases of endophthalmitis with Capnocytophaga species. CONCLUSION: Capnocytophaga species, previously shown to cause necrotizing keratitis, is a potential cause of endophthalmitis, either as a single organism or as part of a mixed infection.

Rearrangement of BCR genes in malignant lymphoma.

The Philadelphia chromosome, originally thought to be associated solely with chronic myelogenous leukemia (CML), has since been identified in acute leukemias and in some cases of lymphoma. The Philadelphia chromosome results from reciprocal translocation of genetic material between chromosome 9 and 22 involving the c-abl and BCR genes respectively. Southern blot analysis of the BCR genes was carried out on biopsy specimens from 49 patients presenting with malignant lymphoma without a previously documented CML phase. In two patients, BCR gene rearrangements were detected in the malignant lymph nodes but not in the bone marrow samples. A third patient showed BCR gene rearrangements in the bone marrow but not in the lymph node. From this limited study, it seems that the overall incidence of BCR gene rearrangement in malignant lymphoma is similar to that observed in adult AML.

The pigtail probe protected by silicone intubation: a combined approach to canalicular reconstruction.

We have devised a method of single-eyelid canalicular reconstruction using the pigtail probe to facilitate identification of the proximal canalicular segment following silicone stent intubation of the normal, uninjured canaliculus. A series of seven acute and two long-standing canalicular lacerations were successfully reconstructed using this technique, which minimizes the risks associated with the use of the pigtail probe.

Cosmetic eyelid surgery and the problem eyelid.

The human eyelid is an amazingly complex structure that is responsible for protecting, moisturizing, and reconstituting the external surface of the eye. Compromise of any of the tarsoligamentous supporting structures of the eyelids can result in eyelid malposition, corneal compromise, and even blindness. Failure to recognize these abnormalities in patients seeking cosmetic eyelid surgery can lead to disastrous results. The most common structural eyelid abnormalities encountered in patients seeking cosmetic eyelid surgery and prophylactic and reconstructive surgical techniques to deal with these difficult problems are discussed.

Keratoconus with acute hydrops and perforation. Brief case report.

Keratoconus is a corneal thinning disorder usually localized to the paracentral cornea. Though acute hydrops has been well described, perforation in keratoconus is an extremely rare event. We report a case of keratoconus with acute hydrops and perforation.

Eyelid necrosis and periorbital necrotizing fasciitis. Report of a case and review of the literature.

Necrotizing fasciitis is an uncommon and severe soft tissue infection characterized by cutaneous gangrene, suppurative fasciitis, and vascular thrombosis. The disease is usually preceded by trauma in patients that have systemic problems, most commonly diabetes and alcoholism. Streptococcus pyogenes and Staphylococcus aureus are the most frequent bacterial etiologies; however, combinations of numerous facultative and anaerobic organisms have also been isolated. Involvement of the face and periocular region is rare. A case is presented here, as well as a review of the clinical features of 15 other patients previously described, in whom eyelid necrosis due to periorbital necrotizing fasciitis developed. Early surgical debridement and drainage of necrotic tissues and appropriate parenteral antibiotics are the mainstay of therapy. The mortality rate in patients with periorbital spread was 12.5%, with the prognosis known to be adversely affected by delay in diagnosis and treatment and/or extension of infection from the face to the neck. Reconstruction of the eyelids with skin grafts was necessary in most cases to avoid such complications as cicatricial lid retraction, lid malpositions, and lagophthalmos.

Establishment of a novel factor-dependent myeloid cell line from primary cultures of mouse bone marrow.

We describe here a novel myelomonocytic cell line (OTT1) obtained from primary cultures of mouse bone marrow cells infected with a retroviral vector carrying the mouse interleukin (IL)-1 alpha gene. OTT1 cells are dependent for their survival and proliferation on IL-3, granulocyte-macrophage colony-stimulating factor (GM-CSF) or, unexpectedly, IL-5. Despite their IL-5 dependency, OTT1 cells form colonies showing predominantly monocyte maturation when plated in methylcellulose. It is suggested that constitutive expression of the exogenous IL-1 alpha gene may predispose to a monocytic phenotype. OTT1 cells should be a useful experimental model to investigate the molecular mechanisms of IL-5 signal transduction and the possible interrelationships between this signal pathway and those utilized by IL-3 and GM-CSF.