The surgical relations of the levator palpebrae superioris muscle.

We conducted a cadaver study of the levator palpebrae superioris muscle to examine several areas of interest that have been reported in the current medical literature. A very strong intermuscular fascia exists between the levator and superior rectus muscles; it is unlikely that a superior rectus bridle suture could pull them apart during cataract surgery. The superior transverse ligament of Whitnall functions to check the posterior movement of the levator; it provides longitudinal support to the resected levator, but does not act as a vertical fulcrum.

Optic nerve evulsion and transection.

Injury to the optic nerve may occur after seemingly minor trauma. Evulsion of the nerve from the globe may be partial or complete as a result of several concussive or rotational forces. A depressed or visibly absent lamina cribrosa indicates a disinsertion of the nerve fibers from the globe. Visual loss ranges from severe to complete. Transections of the optic nerve within the orbit generally occur after penetrating orbital injuries or surgical resection, resulting in complete blindness. Medical or surgical intervention has not been shown to improve the visual prognosis once such injuries occur. The etiology, clinical features, and histopathology are also discussed.

Ocular Munchausen's syndrome.

Patients with contrived histories and/or self-induced physical abnormalities (Munchausen's syndrome) are often successful in deceiving physicians. We recently cared for four patients with ocular Munchausen's syndrome. Self-induced ocular manifestations included voluntary nystagmus, subconjunctival hemorrhages, chronic orbital emphysema requiring exenteration, corneal alkali burns, erosions and ulcerations, and abscesses of the periorbital area. Correct diagnoses of ocular Munchausen's syndrome were made only after extensive medical and surgical investigations. Suggestions for evaluation and treatment will also be discussed.

Functional visual loss in children.

Twenty-three children (16 girls, 7 boys, aged 6-17 years) who presented with the specific complaint of blurred vision were diagnosed as having functional visual loss. Symptoms were intermittent in seven children. Associated signs and symptoms were common and included headaches, visual field loss, diplopia, micropsia, voluntary nystagmus, and spasm of the near reflex. Our treatment consisted of reassurance and follow-up. Resolution of symptoms occurred within 24 hours in one third and within two months in three-quarters of our patients. Parental support and encouragement were associated with more rapid resolution. Recurrence of symptoms and late onset of somatic complaints were rare. Conflicts related to family or school environment were common. Four children had been sexually or physically abused. Our experience suggests that, regardless of the duration or severity of symptoms, functional visual loss in children can usually be treated with reassurance. We believe that psychiatric referral is not necessary for most patients. Sexual or physical abuse should be considered as a possible predisposing factor.

Localized orbital neurofibromas.

Of nine patients (five men and four women, 25 to 55 years old) with localized orbital neurofibromas, only one had other systemic findings consistent with neurofibromatosis. The neurofibromas originated from sensory nerves of the orbit, producing gradual proptosis with expansion of the orbital walls in most cases. Mild orbital discomfort occurred in some patients. Preoperative and postoperative anesthesia in the distribution of the involved sensory nerves was also encountered. Five patients had multiple tumors within the same orbit. Four patients had tumors or a pedicle of the tumor extending into the superior orbital fissure. Two patients were initially thought to have fibrotic pseudotumors. Surgical excision is the treatment of choice for these tumors.