Patency of the lacrimal drainage system in patients with a peripunctal tumour.

Purpose: To examine the patency or secondary obstruction of the lacrimal drainage system in patients with a peripunctal tumour.Methods: This retrospective, observational, and comparative study included 10 patients with a peripunctal tumour. Lacrimal probing and syringing in all patients and dacryoendoscopic examinations in 5 patients were performed to check for patency of the lacrimal drainage system. Tear meniscus height (TMH) was measured bilaterally in the upper and lower eyelids using anterior segment optical coherence tomography and compared in relation to the affected side using one-way ANOVA.Results: All patients did not complain of epiphora. Probing gave a hard stop and irrigation fluid passed into the nose. A patent punctum/canaliculus was also confirmed by dacryoendoscopy in all of the 5 patients. TMH was not significantly different among the sides (P = .900).Conclusions: This study shows patency of the lacrimal drainage system in patients with a peripunctal tumour and no significant difference in TMH among the sides, resulting in absence of epiphora in all patients.

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.

Lacrimal sac lymphoma: A series of Japanese patients.

PURPOSE: To present cases of primary lacrimal sac lymphoma in a Japanese population. METHODS: In this retrospective case series, five cases (two males and three females; mean age: 49.8 years; age range: 38-62 years) were included. Clinical features, diagnostic findings, and treatment outcomes were collected and reviewed. RESULTS: Most patients presented with a swelling or mass in the medial canthal area. Only one patient presented with epiphora, while another patient also complained of pain which was due to inflammation. Imaging studies revealed a lacrimal sac mass with involvement of the nasolacrimal duct and variable involvement of the nasal cavity. Histopathological findings revealed three cases of diffuse large B-cell lymphoma, one case of extranodal marginal zone lymphoma of mucosa-associated lymphoid tissue, and one case of follicular lymphoma. Four cases were treated with a combination of chemotherapy and immunotherapy, with one case necessitating additional radiotherapy. One case was treated with immunotherapy alone. The mean follow-up was 23 (range: 3-50) months. Four cases showed complete remission, while the remaining patient is still ongoing treatment. CONCLUSION: Diffuse large B-cell lymphoma is the most common type of lacrimal sac lymphoma in this series. Lacrimal sac tumors should be ruled out in the presence of epiphora, dacryocystitis, or a mass in the medial canthus, even in the absence of pain or bleeding. Combined chemotherapy and immunotherapy is an effective treatment for these cases.

Bony Orbital Decompression Following Lateral Canthotomy and Cantholysis for Traumatic Orbital Compartment Syndrome.

PURPOSE: To describe the clinical course of patients with traumatic orbital compartment syndrome who underwent bony orbital decompression due to persistently abnormal pupillary light reflex after lateral canthotomy and cantholysis. METHODS: Four consecutive patients were retrospectively reviewed. The authors performed bony orbital decompression as there was no improvement in the pupillary light reflex and a tight orbit persisted even after lateral canthotomy and cantholysis. RESULTS: The median interval between injury and bony decompression was 8.8 hours (range, 7-12 hours). All patients showed a preoperative intraocular pressure of 40 mm Hg or greater, which decreased to 20 mm Hg or less the next day. Two patients showed globe tenting with a posterior globe angle of 110° or less, which was resolved on the following day. Two patients with initial visual acuity of counting fingers or better showed complete visual recovery. By contrast, only 1 of the 2 patients with no light perception slightly improved to light perception while the other showed no improvement after surgery. CONCLUSIONS: Bony orbital decompression is effective for the treatment of traumatic orbital compartment syndrome in patients whose preoperative visual acuity is counting fingers or better.

Differences in Common Orbital Blowout Fracture Sites by Age.

BACKGROUND: The purpose of this study was to compare orbital blowout fracture sites among different age groups. METHODS: This retrospective, observational, comparative study included 671 sides of 663 patients with an orbital blowout fracture. The authors classified patients into five groups based on age (childhood, 0 to 9 years; adolescence, 10 to 18 years; early adulthood, 19 to 44 years; middle adulthood, 45 to 64 years; and late adulthood, 65 years or older); causes of injury into five categories (i.e., sports, traffic accident, assault, fall, and others); and orbital blowout fracture sites into four regions [i.e., the orbital floor lateral (lateral floor) or medial to the infraorbital groove/canal (medial floor); the inferomedial orbital strut (strut); and the medial orbital wall (medial wall)]. RESULTS: A single medial floor fracture was observed in 70.3 percent of patients in the childhood age group. However, the proportion of patients with a single medial wall fracture or multiple fracture sites increased with age. A medial wall fracture was more common than a medial floor fracture in late adulthood. The distribution of orbital blowout fracture sites, the ratio of single or multiple fracture sites, and the causes of injury were statistically different among the age groups (p = 0.005, p = 0.003, and p < 0.001, respectively, Pearson chi-square test). CONCLUSIONS: Common orbital blowout fracture sites varied among age groups. These differences may be attributed to multiple factors, including differences in the morphology of the orbit and paranasal sinuses, composition of the facial bone, and causes of injury among age groups.

Eyelid Myokymia with Concomitant Cerebral Tumour: A Case Report.

Eyelid myokymia is a localised movement disorder of the orbicularis oculi muscle with involuntary, fine, continuous, and undulating contractions. Although this entity is thought to be peripheral nerve origin, it rarely occurs with an intracranial lesion. The authors report a case of eyelid myokymia with concomitant cerebral tumour. A 52-year-old woman had a 6-month history of left eyelid myokymia accompanied by upper eyelid ptosis and lower eyelid reverse ptosis. Magnetic resonance imaging showed a solid mass measuring 20 × 25 × 20 mm in the temporal lobe of the cerebral cortex, showing isointense on T1-weighted and hyperintense on T2-weighted images. The clinical diagnosis was cerebral astrocytoma.

Normative measurements of inferior oblique muscle thickness in Japanese by magnetic resonance imaging using a new technique.

PURPOSE: To measure the thickness of the inferior oblique muscle (IOM) among Japanese by magnetic resonance imaging (MRI) using a new technique. METHODS: This retrospective observational study included 78 patients (36 males and 42 females) who underwent MRI for detection of a unilateral orbital lesion or examining causes of unilateral retrobulbar pain. The thickness of the IOM was measured on the side without the orbital lesion or symptom. On the quasi-sagittal plane through the optic nerve, the major and minor axes of the cross-section of the IOM were measured. On the coronal plane, the maximum thickness perpendicular to the course of the IOM was measured. All measurements were performed using the digital caliper tool of the viewing software. RESULTS: The major and minor axes on the quasi-sagittal plane and the maximum IOM thickness on the coronal plane were 8.00 ± 1.83 mm, 2.98 ± 0.55 mm, 3.04 ± 0.55 mm respectively. There were no significant differences in IOM thickness measurements between sexes and sides (P > 0.050, Student's t-test). No significant correlation with the major axis (r = 0.064, P = 0.576), minor axis (r = -0.065, P = 0.573) or the maximum thickness on the coronal plane (r = -0.099, P = 0.387) was found in relation to age (Pearson's correlation coefficient). CONCLUSIONS: The normative IOM thickness in Japanese was presented on MRI, which were similar among all ages irrespective of sex and side. The new technique we used is easily applicable, and the results may serve as a guide to detect IOM involvement in inflammatory and neoplastic conditions of the orbit.

Adult T-Cell Leukemia/Lymphoma With Primary Lacrimal Gland Involvement.

A 69-year-old Japanese male presented with a 3-month history of bilateral ptosis with lacrimal gland bulge. He came from western Japan, an area endemic for human T-lymphotropic virus Type 1 infection. Physical examination and imaging revealed bilaterally enlarged lacrimal glands. Hematologic testing, biopsy with histopathology, and immunohistochemistry were all consistent with adult T-cell leukemia/lymphoma.

Orbital trapdoor fractures: different clinical profiles between adult and paediatric patients.

BACKGROUND: To compare clinical findings of orbital trapdoor fractures between adult and paediatric patients. METHODS: Paediatric patients were categorised into two groups by age: children (0-9 years) and adolescents (10-19 years). Adult patients were categorised into two groups by age: early (20-44 years) and middle-late adulthood (≥45 years). Demographic data, ocular and periocular complications, CT findings and binocular single vision field (BSVF) were compared among age groups. RESULTS: This study included 105 patients (105 sides, 22 children, 59 adolescents, 14 patients in early adulthood and 10 patients in middle-late adulthood). In patients with fractures of the orbital floor and medial wall, both walls presented as trapdoor fractures in paediatric patients, while one wall presented as a non-trapdoor fracture in adult patients (p=0.061). None of the adult patients showed extraocular muscle incarceration, whereas this was present in 8 of 22 children (36.4%) and 7 of 59 adolescents (11.9%) (p=0.005). Hypoesthesia of the infraorbital nerve more frequently occurred in adults (p=0.004). As the preoperative BSVF was larger in adult than in paediatric patients (p=0.007), the percentage of adult patients who underwent surgical reduction of orbital fractures tended to be lower (p=0.058). Postoperative change in BSVF was smaller in adult patients (p=0.005). CONCLUSIONS: Fracture pattern, type of incarcerated tissue and incidence of hypoesthesia of the infraorbital nerve were different between adult and paediatric patients. Adult patients had a larger preoperative BSVF and less need for surgical reduction; however, there was less improvement in postoperative BSVF.

Orbital fat volume in the inferolateral quadrant in Japanese: a guide for orbital fat decompression without injury to the oculomotor nerve.

PURPOSE: The inferior oblique muscle branch of the oculomotor nerve is susceptible to injury during orbital fat removal from the inferolateral quadrant of the orbit. Understanding the amount of removable orbital fat volume in this quadrant may be helpful in achieving maximum fat decompression without causing nerve injury. The aim of this study was to calculate the orbital fat volume in the inferolateral quadrant using computed tomographic (CT) images. METHODS: In this retrospective, observational study, contiguous 1-mm coronal CT images were obtained from 53 sides (30 patients). The cross-sectional areas of the orbital fat in the inferolateral quadrant were measured from the level just behind the inferior oblique muscle to the orbital apex. The cross-sectional areas reached the inferior oblique muscle branch medially, the lateral orbital wall laterally, the inferior edge of the lateral rectus muscle superiorly, and the orbital floor inferiorly. An integrated value between the cross-sectional areas and the CT slice thickness was calculated. RESULTS: The mean orbital fat volume in the inferolateral quadrant was 3.9 ± 1.4 mL (range: 1.3-7.0 mL). Multiple regression analysis demonstrated a significant relationship between orbital fat volume and Hertel exophthalmometry measurement (adjusted r 2 = 0.101; P = 0.012), although the thickness of the lateral and inferior recti muscles was deleted from the regression equation by stepwise process. CONCLUSIONS: The orbital fat volume in the inferolateral quadrant can serve as a guide for orbital fat removal without causing injury to the inferior oblique muscle nerve branch.

Bell's phenomenon in thyroid-associated inferior rectus myopathy.

PURPOSE: To examine Bell's phenomenon in patients with unilateral thyroid-associated inferior rectus myopathy and changes in this phenomenon after inferior rectus muscle recession. METHODS: This prospective interventional study included 12 patients who underwent inferior rectus muscle recession with or without nasal transposition. Bell's phenomenon was examined before and 3 months after surgery. The upper eyelid was held open by a finger to prevent complete eyelid closure. Then, the distance of upward excursion of the inferior corneal limbus or the corneal light reflex was measured during voluntary maximum forced eyelid closure. The pre- and postoperative distances of upward excursion on the affected side were statistically compared with the preoperative distance on the unaffected side using the Mann-Whitney U test, and the pre- and postoperative distances on the affected side were statistically compared using paired t-test. The relationships among postoperative changes of Bell's phenomenon, patient age, the amount of recession and nasal transposition of the inferior rectus muscle, postoperative angle of ocular deviation, and reduction in the angle after surgery were analyzed using stepwise multiple regression analyses. RESULTS: The preoperative measurement of Bell's phenomenon was significantly shorter on the affected side (1.6 ± 1.6 mm) than the unaffected side (4.3 ± 1.6 mm; P = 0.001). However, the distance on the affected side significantly increased after surgery (4.1 ± 1.9 mm; P < 0.001), compared to the preoperative distance on the unaffected side (P = 0.843). Using a stepwise method, all variables were deleted from the regression equation. CONCLUSIONS: Bell's phenomenon decreased on the affected side, which improved after inferior rectus muscle recession.

Incarceration of the inferior oblique muscle branch of the oculomotor nerve in patients with orbital floor trapdoor fracture.

PURPOSE: To examine the clinical characteristics of patients with concomitant incarceration of the inferior oblique muscle branch of the oculomotor nerve who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. METHODS: Fifty-nine patients were retrospectively reviewed. Concomitant inferior oblique muscle branch incarceration was diagnosed by inferior oblique muscle underaction on the Hess chart and a missing inferior oblique muscle branch on computed tomographic images on baseline examination. RESULTS: Eleven patients (18.6%) were diagnosed with concomitant branch incarceration. The patients with branch incarceration were all under 19 years of age, and were younger than those without branch incarceration (P = 0.026). There were no significant differences between the groups in terms of cause of injury, presence of concomitant medial wall fracture, hypoesthesia of the cheek region, or ocular and periocular complications (P > 0.050). All patients with branch incarceration underwent surgical reduction, whereas 16 of 48 patients without branch incarceration were observed without surgery (P = 0.021). Although preoperative binocular single vision field was smaller in patients with branch incarceration (P = 0.026), it improved after surgery, comparable to that of patients without branch incarceration (P = 0.079). CONCLUSIONS: Concomitant incarceration of inferior oblique muscle branch of the oculomotor nerve occurred in 18.6% of patients who had suffered from an orbital floor trapdoor fracture with orbital fat incarceration. Patients with branch incarceration were all under 19 years of age. Branch incarceration resulted in a smaller binocular single vision field, which considerably improved after surgical reduction.

Lacrimal Caruncle Nevus with Papilloma.

PURPOSE: The aim of this article is to report a case of lacrimal caruncle nevus with papilloma. METHODS: This is a case report of a 39-year-old female with a progressively enlarging pigmented lesion on the left lacrimal caruncle. She had been aware of a raised whitish wart on the top of this pigmented lesion for several months before her initial visit. Slit lamp examination revealed a papillomatous lesion over a well-circumscribed, pigmented lesion on the left lacrimal caruncle. RESULTS: The histopathological examination of the excised tumor disclosed 2 characteristic findings, which include nests of nevus cells within the dermis and papillomatous structures which had fibrovascular cores overlying squamous cell epithelia with variable levels of acanthosis. The findings were consistent with an intradermal nevus and a papilloma arising from the conjunctival epithelium of the nevus. CONCLUSION: This is the first case report of a lacrimal caruncle nevus with papilloma. The clinical history and pathological findings of this case underscore the fact that an intradermal nevus primarily occurred on the lacrimal caruncle, after which a papilloma arose from the epithelium of the nevus as a consequence of human papillomavirus autoinoculation.