Presentation and outcomes of orbital cellulitis caused by Group F Streptococcus.

PURPOSE: To compare the presentation and outcomes of patients with orbital cellulitis requiring surgical intervention caused by the Group F Streptococcus (GFS) versus other bacteria. We hypothesize that patients with GFS infections have a more severe presentation and worse clinical outcomes compared to infections by other bacteria. METHODS: After Institutional Review Board approval at a large academic institutional center, 70 patients with culture-positive orbital cellulitis who required surgical intervention were identified. Clinical examinations before and after surgery as well as preoperative imaging with computed tomography and/or magnetic resonance imaging were reviewed. The study measures were preoperative and postoperative vision, motility, involved sinus disease, complications, and total hospital length of stay. Multiple imputation was used for missing data. Characteristics of patients were compared using Chi-square and Wilcoxon rank-sum. RESULTS: Nineteen patients (27%) had positive cultures for GFS and 51 patients (73%) had positive cultures for other bacterial species. There was no significant difference in visual acuity, motility, or inflammatory markers in patients with GFS compared to other patients. Patients with GFS were noted to have more sinus involvement on presentation compared to patients with other bacterial infections (P = 0.007). CONCLUSION: GFS associated orbital cellulitis is associated with significantly more sinus involvement, but has similar outcomes as orbital cellulitis from other bacterial species.

Delayed periorbital hemorrhage in oculoplastic surgery patients on oral anticoagulants.

Periorbital hemorrhage is a potentially sight threatening surgical complication. The effect of new oral anticoagulants (NOACs) on hemorrhagic events after periorbital surgery has not been investigated. We describe four cases of severe delayed postoperative hemorrhage associated with NOACs, in addition to three cases in patients on traditional antithrombotic agents. Time of delayed hemorrhage ranged from postoperative day 2 to 6. Six patients required surgical intervention to achieve control of bleeding, and two patients required transfusion of blood products. Risk factors and management of this rare complication are discussed.

A Report of Intracranial Meningioma Recurring as Ectopic Orbital Meningioma Associated With Basal Encephalocele.

The authors describe a rare case of recurrent ectopic meningioma associated with sphenoid encephalocele in the medial anterior orbit of a 52-year-old man with a history of a resected intracranial meningioma. Typical features of ectopic meningioma are reviewed as well as potential etiologies of this very rare recurrence of intracranial meningioma in the orbit. Treatment is typically surgical excision.The authors report a rare case of recurrent orbital ectopic meningioma in the right medial canthus of a 52-year-old man.

Intraorbital Graphite Foreign Body With a Delayed Presentation of Optic Neuropathy.

Traumatic penetrating injuries to the orbit from pencils, while uncommon, have a plethora of presentations, both acute and delayed. With the most incidents occurring in the pediatric population where obtaining a detailed history is difficult, the ability to effectively evaluate and diagnose these injuries is cumbersome, yet important. The authors report a patient who presented with optic neuropathy, blepharoptosis, and strabismus 10 months after an orbital injury with pencil graphite.

Effect of Time to Operative Intervention on Motility Outcomes Following Orbital Floor Fracture Repair in Children.

PURPOSE: To evaluate the relationship between time to surgical intervention and extraocular motility outcomes in children following repair of an orbital floor fracture with inferior rectus entrapment. METHODS: After institution review board's approval, a retrospective, consecutive case series of 28 children with unilateral orbital floor fractures entrapping the inferior rectus muscle was conducted. Clinical examinations and CT images were performed on all children. The main outcomes measures were postoperative motility measurements. RESULTS: Eleven patients underwent surgery within 24 hours of reported injury, while 17 patients underwent surgery after 24 hours. There was no statistically significant difference in average age at the time of surgery (p = 0.47) or average preoperative motility scores (p = 1.0) between the 2 groups. Patients who underwent surgery within 24 hours of reported injury had an improved likelihood of recovery (log hazard ratio = 0.469; 95% confidence interval, -0.42 to 1.36). CONCLUSIONS: Our exploratory study suggests that surgical reduction of inferior rectus entrapment in pediatric orbital floor fractures within 24 hours from the time of injury shows an improved, but nonstatistically significant, likelihood of recovery in motility deficits with earlier surgical intervention.

Neuroepithelial Cyst of the Optic Nerve in a Newborn.

Cystic lesions of the optic nerve are uncommon findings that have been associated with neoplasms, systemic disorders, or described as idiopathic. They have been described in a wide range of ages, with few congenital cysts having been described in infants. Surgical excision of these lesions may lead to significant morbidity as previously reported cases often involved transection of the optic nerve. The authors describe a unique case of a newborn with a rare neuroepithelial cyst of the intraorbital optic nerve that was successfully excised while sparing the optic nerve, ultimately resulting in the resolution of an afferent pupillary defect. This case demonstrates that careful surgical excision of a benign optic nerve cyst can be performed without significant morbidity to potentially preserve vision.

Congenital Tonic Pupils Associated With Congenital Central Hypoventilation Syndrome and Hirschsprung Disease.

Autonomic dysfunction can be associated with pupillary abnormalities. We describe a rare association of tonic pupils, congenital central hypoventilation syndrome, and Hirschsprung disease in a newborn with a mutation in the PHOX2B gene, a key regulator of neural crest cells. Hirschsprung disease is characterized by the congenital absence of neural crest-derived intrinsic ganglion cells. Tonic pupils may result from an abnormality of the ciliary ganglion, another structure of neural crest origin. The close association of these conditions in this child suggests a common abnormality in neural crest migration and differentiation.

Socioeconomic Disparities in the Presentation of Acute Bacterial Sinusitis Complications in the Pediatric Population.

Acute bacterial sinusitis is a common disease in the pediatric population that typically resolves without significant complications. Children who do suffer from complications involving the orbit or the brain often experience significant morbidity and potential mortality, typically requiring hospitalization for management. Numerous studies have demonstrated that children from low-income families with public or no insurance are less likely to receive adequate preventative care, are more likely to present with later disease stages, and ultimately endure worse health outcomes. We review the literature to examine if there are socioeconomic disparities in the presentation of complications of acute bacterial sinusitis in the pediatric population.

Intralesional tetracycline injection for treatment of lower eyelid festoons: a preliminary report.

PURPOSE: To determine the safety and effectiveness of intralesional tetracycline 2% injection for the treatment of lower eyelid festoons. METHODS: The authors retrospectively reviewed the charts of all patients undergoing tetracycline 2% injection of lower eyelid festoons at the Cole Eye Institute from August 2008 to August 2013. Charts were reviewed for patient demographic data, dose and number of tetracycline injections, follow-up interval, the presence of preinjection and postinjection photographs, and complications. Charts without preinjection and postinjection photographs were excluded from review. The preinjection and postinjection photographs were randomized, masked, and graded by 4 independent examiners. Photographs were graded on a scale of 0 (no festoon) to 4 (severe festoon). Student t test was used for statistical analysis. RESULTS: Eleven patients met inclusion criteria. Each patient underwent bilateral injection. Average follow up was 121 days (range, 18-586 days). Patients received up to 0.75 ml (mean, 0.24 ml) of tetracycline 2% per side. Average preinjection grade was 2.1 (standard deviation, 0.89; range, 0-3), and average postinjection grade was 1.2 (standard deviation, 0.72; range, 0-2; p < 0.001). Three patients had follow up less than 60 days (mean, 34 days), with an average preinjection grade of 1.96 and postinjection grade of 1.23 (p < 0.001). Five patients had follow up between 60 and 100 days (mean, 82 days), with an average preinjection grade of 2.18 and postinjection grade of 1.38 (p < 0.001). Three patients had follow up longer than 100 days (mean, 275 days), with an average preinjection grade of 2.08 and postinjection grade of 0.78 (p < 0.001). Complications other than pain and bruising were not identified in any patient. CONCLUSIONS: Intralesional tetracycline 2% injection may offer a safe option to treat lower eyelid festoons. Complications such as cutaneous ischemia or necrosis were not identified in any patient. Further study may determine optimal treatment doses and intervals and detect infrequent but significant complications.

Blepharoptosis repair outcomes from trainee versus experienced staff as the primary surgeon.

PURPOSE: To compare outcomes of conjunctival Müllerectomy with or without tarsectomy versus external levator advancement for correction of upper blepharoptosis when performed by trainee versus staff surgeons. DESIGN: Retrospective, nonrandomized, interventional, consecutive case series. METHODS: Charts of patients undergoing conjunctival Müllerectomy with or without tarsectomy and external levator advancement blepharoptosis repair from January 2006 through December 2009 were reviewed. Main outcome measures included age, gender, preoperative and postoperative use of artificial tears, preoperative and postoperative marginal reflex distance, surgical complications, surgeon (trainee or staff surgeon), and anesthesia time. The Student t test was used for statistical analysis. RESULTS: A total of 170 patients underwent 248 surgeries (154 conjunctival Müllerectomies with or without tarsectomy and 94 external levator advancements). There were 108 female and 62 male patients. Mean patient age was 62 years (range, 3 to 94 years). Forty-one (24%) patients (26 conjunctival Müllerectomies with or without tarsectomy and 15 external levator advancements) underwent concurrent eyelid surgery, such as blepharoplasty. Trainees performed surgery on a total of 88 (35%) eyelids in 60 patients (35%). There was no significant difference in the percentage of cases undergoing concomitant surgery between trainee and staff surgeons (P = .18). The mean postoperative marginal reflex distance difference was 0.53 and 0.59 for trainee and staff surgeons, respectively. Mean overall anesthesia time was 26.8 minutes and 30.3 minutes for trainee and staff surgeons, respectively. Complications, including increase in dry eye or irritative symptoms and reoperation, occurred in 8 (13%) of 60 patients undergoing surgery by a trainee surgeon and in 22 (20%) of 110 patients undergoing surgery by staff surgeon. There was no significant difference in eyelid symmetry (P = .55), mean anesthesia time (P = .14), complication rate (P = .26), or reoperation rate (P = .17) when surgery was performed by a trainee versus a staff surgeon. CONCLUSIONS: There is no significant difference in mean postoperative marginal reflex distance, mean anesthesia time, complication rate, or reoperation rate between either conjunctival Müllerectomy with or without tarsectomy or external levator advancement blepharoptosis repair performed by trainee versus staff surgeons.