Involutional lower eyelid entropion: causative factors and therapeutic management.

PURPOSE: To summarize proposed causative factors and the outcomes of surgical practices for involutional lower eyelid entropion. METHODS: We reviewed the literature on proposed causative factors and the outcomes of surgical practices for involutional lower eyelid entropion, searched on PubMed. RESULTS: Vertical and horizontal laxities of the lower eyelid, and overriding of the preseptal orbicularis oculi muscle onto the pretarsal orbicularis oculi muscle have been proposed as the major causes of involutional lower eyelid entropion. Treatment procedures have been developed over the years to address one or more of these causative factors. CONCLUSIONS: Various causative factors and treatment procedures have been advocated to explain and correct involutional lower eyelid entropion. The appropriate procedure is chosen according to the patient's condition, such as the presence of vertical laxity, horizontal laxity, and orbicularis oculi muscle overriding. A combination of these procedures to correct multiple factors further decreases the recurrence rate.

Rescue technique for complete removal of an accidentally ruptured orbital dumbbell deep dermoid cyst: A case report.

PURPOSE: To report a rescue technique for complete removal of an accidentally ruptured orbital dumbbell deep dermoid cyst. OBSERVATIONS: A 33-year-old female presented with left proptosis with retrobulbar discomfort for 3 months. Computed tomography images showed an orbital dumbbell deep dermoid cyst. A lateral orbitotomy was performed under general anesthesia. The cyst was ruptured during osteotomy of the lateral orbital rim. The cyst was opened vertically from the ruptured site using a Stephen's tenotomy scissors to visually confirm the internal wall of the cyst and to keep the epithelial lining intact while separating the external wall of the cyst from the bone. There was a small defect of the epithelial lining at the inferoposterior margin of the cyst. Granulomatous inflammation of the lacrimal gland was found adjacent to the defect site. The cyst was completely removed and the lacrimal inflammation subsided after the operation. CONCLUSIONS AND IMPORTANCE: Opening of the cyst is a useful technique to remove the entire epithelial lining of an accidentally ruptured dumbbell dermoid cyst.

Lagophthalmos caused by cicatricial adhesion of orbital adipose tissue to orbital roof: A case report.

PURPOSE: To report a case of lagophthalmos caused by cicatricial adhesion of orbital adipose tissue to the orbital roof. OBSERVATIONS: A 23-year-old female was presented with right lagophthalmos. Five months prior to consult at our clinic, she suffered from a penetrating trauma to the frontal lobe of the brain through the right orbital roof with cerebrospinal fluid leakage. Decompressive craniectomy was performed immediately after the injury using a coronal incision, which was followed by reconstruction with an artificial bone 1 month later. On examination at our clinic, she showed right exposure keratopathy with best corrected visual acuity of 20/100 due to corneal opacity. The palpebral contracted scar was first elongated using Z-plasty technique but excursion of the upper eyelid under a finger force assistance was insufficient to eliminate lagophthalmos. However, complete eyelid closure under a finger force assistance was achieved after sharp dissection of the cicatrized adipose tissue from the orbital roof. An autogenous dermis-fat was grafted on the orbital roof and superior orbital rim to avoid adhesion of orbital adipose tissue onto the bone again. CONCLUSION AND IMPORTANCE: Cicatricial adhesion of an orbital adipose tissue to the orbital roof is one of the possible causes of posttraumatic lagophthalmos in patients with an orbital roof fracture. Surgeons need to be aware of this condition in planning of surgical repair when such a fracture is encountered.

Interlower and postlower eyelid retractor fat pads: a cadaveric microscopic study.

BACKGROUND: To report the histological microscopic anatomy of the interlower and postlower eyelid retractor (LER) fat pads. METHODS: In this experimental microscopic study, 31 exenterated orbits from 31 Japanese cadavers (19 right and 12 left; 15 male and 16 female; mean age of death, 81.0±8.8 years; range, 52-97 years) fixed in 10% buffered formalin were used. Masson trichrome was used to stain sagittal full sections of exenterated tissues. Microscopic examination of the lower eyelids was carried out. RESULTS: The exenterated orbits demonstrated the presence of the histological existence of inter-LER fat pad (80.6%) and post-LER fat pad (22.6%) in the lower eyelids. The inter-LER fat pad was thick and located between the anterior and posterior layers of the LER, where the blood vessels passed through in 18 specimens (72.0%). The post-LER pad was thin, subtle and located between the posterior layer of the LER and conjunctiva. CONCLUSION: This study reports a novel finding of the inter-LER and post-LER fat pads. Awareness of these fat layers provides surgeons with additional anatomical detail of lower eyelid anatomy.

Bilateral orbital marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue in a patient with hepatitis B virus infection.

PURPOSE: To report a case of marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) in the bilateral orbit with chronic hepatitis B virus (HBV) infection. OBSERVATIONS: A 72-year-old man with chronic HBV infection presented with a bilateral proptosis with slight restriction of ocular motility for 9 months. Computed tomographic images showed well-defined, isodense masses in the bilateral superolateral orbit. Magnetic resonance images showed isointense on T1-and hyperintense on T2-weighted images, with bilateral involvements of the lateral rectus muscles reaching the superior orbital fissures. These masses molded along the globe contour. Incisional biopsies via upper eyelid crease were performed on both lesions. The immunohistopathological diagnosis was MALT lymphoma. CONCLUSIONS AND IMPORTANCE: This case showed a possible association between orbital MALT lymphoma and HBV.

Orbital myxoma comorbid with acute myelomonocytic leukemia.

We report the first case of orbital myxoma in a 10-year-old girl with a history of acute myelomonocytic leukemia diagnosed at the age of 10 months. She presented with a mass in the right orbit, which was excised completely. There was no recurrence during the 6 months of follow-up.

Accidental Ingestion of Nasal Packing Gauze during Endonasal Endoscopic Dacryocystorhinostomy under Local Anesthesia: A Case Report.

PURPOSE: To report a case of accidental ingestion of a nasal packing gauze during endonasal endoscopic dacryocystorhinostomy (en-DCR) under local anesthesia. CASE REPORT: A 66-year-old female patient underwent an en-DCR for a right acquired nasolacrimal duct obstruction. The surgery was performed in a supine position under local anesthesia. An X-ray detectable ribbon gauze soaked in 0.02% epinephrine was placed in the middle meatus to prevent blood and liquid from flowing into the pharynx. The same packing gauze was also used for hemostasis during the surgery. At the end of the surgery, 1 piece of gauze was missing and could not be detected by the endonasal endoscopic exploration. An abdominal X-ray image performed on the same day demonstrated the presence of the gauze in the stomach although the patient did not notice swallowing the gauze. The gauze was not there on the X-ray 1 week later. CONCLUSION: Surgeons need to be aware of accidental ingestion of a nasal packing gauze in en-DCR under local anesthesia. Keeping the gauze end out of the nostril is likely preventive for this complication. The use of X-ray detectable gauze was helpful to detect its location.

Cystic mucosa-associated lymphoid tissue lymphoma of lacrimal gland associated with vision loss: A case report.

PURPOSE: To report an atypical case of cystic extranodal marginal zone B-cell lymphoma of mucosa-associated lymphoid tissue (MALT lymphoma) of lacrimal gland associated with vision loss. OBSERVATIONS: An 89-year-old woman was presented with a rapidly progressing proptosis, lagophthalmos, and vision loss. Endophthalmitis was also present. Computed tomography scan images showed a hyperdense mass with hypodense cystic areas occupying the superolateral orbit, which displaced the globe antero-inferiorly with optic nerve compression and stretching. An erosion to the adjacent superior and lateral orbital walls was also demonstrated. Complete tumor excision was performed via upper transconjunctival orbitotomy concurrently with enucleation. The immunohistopathological diagnosis was MALT lymphoma. CONCLUSIONS AND IMPORTANCE: This case emphasizes the importance of considering lymphoma in the differential diagnosis of a cystic superolateral orbital mass.

Primary Marginal Zone B-Cell Lymphoma of the Mucosa-Associated Lymphoid Tissue of the Lacrimal Sac Found with Epiphora: A Case Report.

We report a case of a primary marginal zone B-cell lymphoma of the mucosa-associated lymphoid tissue of the lacrimal sac, which was found in a patient with epiphora without palpable mass. Magnetic resonance imaging demonstrated mucosal thickening of the lacrimal sac with a patent lumen, consistent with the intraoperative finding. Epiphora resolved, which was confirmed by smooth syringing, 1 month after starting the immunotherapy.

Solitary Fibrous Tumor in the Lacrimal Gland Fossa: A Case Report.

Solitary fibrous tumors (SFTs) are benign, spindle-cell tumors of mesenchymal origin that are usually seen in the superior orbital area in adults. We report a rare case of SFT in the lacrimal gland fossa that developed in a young female. A 25-year-old woman had a 6-month history of a progressive painless mass in the left upper eyelid accompanied by proptosis. Computed tomography and magnetic resonance imaging showed an ovoid, demarcated mass with distinct margins in the lacrimal gland region without bone invasion. Excision biopsy with immunohistochemical study, specifically with positive signal transducer and activator of transcription 6, confirmed the diagnosis.

Prevention of re-obstruction in watery eye treatment: three-flap technique in external dacryocystorhinostomy.

PURPOSE: To examine the surgical outcome of three-flap external dacryocystorhinostomy (3-flap ex-DCR) based on the most common site of granulation occurrence in no-flap endonasal DCR (no-flap en-DCR). METHODS: This was a retrospective observational study. We first examined the location of granulation occurrence in the osteotomy site using nasal endoscopy after no-flap en-DCR on 53 sides of 37 patients (5 male, 32 female) with nasolacrimal duct obstruction. Based on the results of this surgery, we performed 3-flap ex-DCR on 70 sides of 61 patients (18 male, 43 female) with nasolacrimal duct obstruction. Anatomical success was defined as no reflux under lacrimal irrigation and a patent osteotomy site under nasal endoscopic examination at postoperative 12 months. Functional success was defined as no symptoms of watery eyes over the same period. RESULTS: In the no-flap en-DCR patients, the granulation was formed in 42 sides (79.2 %): 18 sides (34.0 %) on the superior portion, 9 sides (17.0 %) on the inferior portion, 35 sides (66.0 %) on the anterior portion, and only 1 side (1.9 %) on the posterior portion, which was very small. Based on these results, we performed the 3-flap ex-DCR with the anterior, superior, and inferior flaps. Anatomical success with this technique was achieved in all sides (100 %), and functional success was obtained in 66 of 70 sides (94.3 %). CONCLUSIONS: The 3-flap ex-DCR did not cause recurrent nasolacrimal duct obstruction, rendering it a very useful technique in terms of quality of life and medical economics.

Risk Factors for Local Recurrence or Metastasis of Eyelid Sebaceous Gland Carcinoma After Wide Excision With Paraffin Section Control.

PURPOSE: To identify risk factors for local recurrence and metastasis of sebaceous gland carcinoma (SGC) after wide excision with paraffin section control. DESIGN: Retrospective, observational case-control study. METHODS: Setting: Single institution. PATIENT POPULATION: Thirty-four patients with SGC who had undergone excision with 5-mm surgical margins and paraffin section pathologic analysis. Observational Procedures: The following were considered potential risk factors for local recurrence/metastasis of SGC: patient's sex, patient's age, initial diagnosis at other clinics, topical treatments at other clinics, interval between appearance of symptoms and referral to our institution, tumor location, tumor origin, tumor presentation pattern, T category, tumor size, presence/or absence of pagetoid spread, tumor differentiation, mitosis grade, growth pattern. Logistic regression analysis was performed to identify the actual risk factors. MAIN OUTCOME MEASURES: Risk factors for local recurrence or metastasis of SGC after wide excision with paraffin section control. RESULTS: Involvement of both upper and lower eyelids, topical treatments at other clinics, multicentric origin, diffuse pattern, stage T3a, large tumor size, and a nonlobular pattern significantly influenced local recurrence/metastasis (P < .050). Pagetoid spread tended to affect local recurrence/metastasis (P = .052). The other items did not significantly influence local recurrence/metastasis (P > .050). CONCLUSIONS: This study identified risk factors for local recurrence or metastasis of SGC after wide excision with paraffin section pathologic analysis. The results of this study will be helpful to surgeons when planning additional management, such as map biopsy or adjuvant treatment.

Characteristics of Dehiscence of Lamina Papyracea Found on Computed Tomography Before Orbital and Endoscopic Endonasal Surgeries.

The aim of this study was to identify characteristics of dehiscence of the lamina papyracea found on computed tomography (CT) before orbital and endonasal endoscopic surgeries.The authors retrospectively reviewed the medical records of all patients who underwent orbital tumor removal, orbital decompression, and dacryocystorhinostomy from January 2012 to December 2015. The diagnosis of dehiscence of the lamina papyracea was made based on a bone defect with protrusion of orbital fat into the ethmoid sinus on CT, with no history of orbital trauma and/or eye movement disturbance on the same side.Overall, 6 patients (1.4%) were identified from among 315 patients (90 orbital tumors, 150 orbital decompressions, and 75 endoscopic endonasal dacryocystorhinostomies). All patients were asymptomatic. All dehiscence was limited to the anterior ethmoid sinus, with fat prolapse of <1 cm. An opacified ethmoid sinus was found in 1 of the 6 patients (17%) with dehiscence of the lamina papyracea. Operative area included the dehiscence site in 1 patient. Intraoperatively, the periorbita was found to be defected at the dehiscence site with intact connective tissue septa. The dehiscence site served as a landmark for the operation.Dehiscence of the lamina papyracea is a rare anomaly, but occasionally encountered in orbital and endoscopic endonasal surgeries.