Orbital Volume Augmentation with Calcium Hydroxyapatite Filler in Anophthalmic Enophthalmos.

PURPOSE: To report the long-term results of orbital volume augmentation using calcium hydroxyapatite filler injections in patients with anophthalmic sockets. METHODS: Twelve eligible patients with post-enucleation socket syndrome (PESS) and small orbital volumes were included in our study. In this investigation, 1.5 mL injectable calcium hydroxyapatite (Radiesse) was utilized in an off-label application under local anesthesia. We evaluated the effect of orbital volume augmentation for correction of enophthalmos. RESULTS: Five women and seven men with a mean age of 35 years (range, 21-72 years) were included in the study. The mean follow-up was 19.5 months (range, 16-27 months). Enophthalmos and deep superior sulcus were reduced in all patients during all follow-up visits postoperatively. The mean improvement of enophthalmos was 2.58 mm (range, 1-5 mm) and the improvement in deformity grading of superior sulcus was 0.83 (range, 0-4 grade). The mean marginal reflex distance increased by 0.6 mm (range of -1 to 3 mm). Complications included increase in ptosis in two cases and extrusion of the filler accompanied by discoloration of the skin in one case. CONCLUSION: The use of injectable calcium hydroxyapatite for orbital volume restoration in anophthalmic sockets is a simple, fast, and minimally invasive method with considerable long-term effects and low complications.

Infantile Periocular Hemangioma.

Infantile periocular hemangiomas (IPH) are common benign vascular tumors that present early in childhood. They typically show a rapid nonlinear growth pattern a few weeks after birth during a proliferative phase, then continue with an involution phase and may result in serious ocular or systemic complications. Theses tumors may present in a range of small isolated lesions to multiple, diffuse involvements. Understanding the nature of the disease, the natural course, complications, indications for intervention, and treatment modalities would be helpful for ophthalmologists, who will likely be consulted for periocular cases. In this review, we present recent opinions about the pathogenesis, diagnosis, and treatment options for patients with IPH.

Traumatic Canalicular Laceration Repair with a New Monocanalicular Silicone Tube.

PURPOSE: This study evaluated the efficacy of a new pushed monocanalicular silicone tube in reconstructing traumatic canalicular laceration. METHODS: This interventional case series enrolled 48 patients with a traumatic canalicular laceration. Patients with bicanalicular involvement were excluded. Canalicular repair was performed under an operating microscope and involved proximal end exploration of the canaliculus, stenting of the canaliculus with a 35-mm Masterka tube, and approximation of the lacerated canaliculi margins. After 6 months, anatomical and functional success rates were evaluated by diagnostic probing and by asking the patients (or their guardians) about tearing. RESULTS: The mean age of patients was 32.2 ± 21.2 years (1.5-75 years). Of the 48 patients included, 38 were males. Lower canaliculus was involved in 35 patients. Other ocular injuries were observed in 38 patients. The average interval between the surgery and Masterka removal was 12.2 ± 1.4 weeks (10-16 weeks). Early tube extrusion was observed in 3 patients. No significant complication was observed in this series. Anatomical and functional success rates were 87% and 100%, respectively. CONCLUSION: The results demonstrated that intubation of lacerated canaliculi with Masterka tube for canalicular repair was safe, effective, and simple with minimal complications.

A very rare case of eyelid metastasis originating from lung adenocarcinoma.

PURPOSE: To report a very rare eyelid mass confirmed to be a metastasis from lung adenocarcinoma. METHODS: A 68-year-old man had a two-month history of a large nodule in the right upper eyelid. He was a known case of lung adenocarcinoma since 2 years without a history of systemic metastasis. He underwent further investigations including orbital imaging and biopsy of the lesion. RESULTS: Biopsy and immunohistochemical evaluations of the eyelid lesion revealed a moderate to poorly differentiated adenocarcinoma, a similar histology to the lung lesion. CONCLUSIONS: Metastatic involvement of the eyelids is rarely seen; specifically, those associated with lung adenocarcinoma as the source have been reported extremely rare. Eyelid metastases present with various and non-specific clinical features, and therefore biopsy of suspicious or recurrent lesions is highly recommended to rule out such malignant processes.

Efficacy of tightening of orbicularis oculi muscle in patients with functional nasolacrimal duct obstruction.

PURPOSE: To evaluate the efficacy of tightening of lateral portion of orbicularis oculi muscle in patients with functional nasolacrimal duct obstruction (FNLDO). METHODS: This is an interventional cross-section study for evaluation of effect of orbicularis oculi tightening procedure in patients with FNLDO. Patients with unexplained epiphora, open lacrimal system in syringing and evidences of lacrimal pump weakness in lacrimal scintigraphy underwent surgery. In this procedure, a stripe of preseptal and pretarsal orbicularis muscle was dissected, slightly resected and secured to the periosteum of lateral orbital rim. Each subject completed a questionnaire about the intensity of epiphora before surgery and 1, 3 and 6 months after surgery. Furthermore, fluorescein dye disappearance test (FDDT) was performed before surgery and repeated in the follow-up visits. At last visit, the pre- and post-operative data were analyzed and compared. RESULTS: Fifteen eyes of 12 patients (5 males and 7 females) with the mean age of 56.7 years included in the study. Severity of epiphora and tearing effect on daily life were significantly improved following the operation. FDDT result was improved significantly after 1 month follow-up in all eyes (15 eyes), at 3 months follow-up in 80% of eyes (12 eyes) and at the end of the 6th month in 66.7% of eyes (10 eyes). Subjective and objective success rates were 87% and 80%, respectively. No significant complications or side-effects were observed. CONCLUSION: Tightening of lateral portion of preseptal and pretarsal orbicularis muscle seems an effective, safe, and easy procedure to decrease epiphora in patients with FNLDO.

Eyelid masses: a 10-year survey from a tertiary eye hospital in Tehran.

PURPOSE: The purpose of this study was to evaluate the demographics and clinical features of eyelid masses in a tertiary eye hospital over a 10-year period. MATERIALS AND METHODS: A retrospective chart review was performed for patients admitted with eyelid tumors from 2000 to 2010. Data were collected and analyzed on the demographic features, location of the tumor, types of treatment, and pathologic findings. RESULTS: A total number of 182 patients were evaluated of which, 82 cases were benign and 100 cases were malignant neoplasms. The most common benign tumors included melanocytic nevi (35%), papilloma (19.5%), and cysts (11%). The most frequent malignant tumors included basal cell carcinoma (BCC) (83%), squamous cell carcinoma (8%) and sebaceous gland carcinoma (6%). The most common site for malignancy was the lower lid followed by the upper lid. BCC recurred in 16 cases that were most frequent in the lower lid. CONCLUSION: Melanocytic nevus, papilloma and cysts are the most common benign lesions and BCC is the most common malignant lesion in the eyelids. Recurrence is a feature of BCC especially in the lower lid.

Modified frontalis sling procedure with lid crease formation.

PURPOSE: To report the results of a modified frontalis sling procedure using Mersilene mesh for correction of upper lid ptosis associated with poor levator muscle function. METHODS: This interventional case series included 10 patients (15 eyelids) with congenital ptosis and poor levator function. All subjects underwent the upper lid sling procedure with modifications. Main outcomes were lid crease height and position. RESULTS: Overall, 15 eyelids from ten patients including 7 male and 3 female subjects underwent surgery. After a mean period of 10.2±2.8 months, all cases had symmetrical lid crease and contour; upper lid margin to corneal reflex distance and lid fissure were both increased significantly. CONCLUSION: This modified frontalis sling procedure may be considered as an alternative to conventional surgery; this method provides good cosmesis and is associated with a low rate of reoperations.

Granular cell tumor of the orbit.

PURPOSE: To report a case of granular cell tumor as a rare orbital pathology. CASE REPORT: A 50-year-old female presented with a 4-year history of diplopia, right ocular displacement and a firm nontender mass in her right lower lid. Computed tomography (CT) scan of the orbit disclosed a well-defined mass in the right inferior orbit involving the right inferior rectus. Subtotal excision of the mass was performed, and histopathologic and immunohistochemical studies revealed granular cell tumor. Subsequently, the tumor recurred and exenteration was required as multiple sessions of radiotherapy failed to prevent the residual tumor from growing. CONCLUSION: Granular cell tumor, though very rare in the orbit, should be considered in patients with orbital masses especially in cases with involvement of the inferior rectus muscle. Infiltrative tumors may be impossible to completely resect and can rapidly recur following surgery.

Orbital paraganglioma presenting as lateral rectus enlargement and its novel management: a case report and review of literature.

Paragangliomas of the orbit are extremely rare. We report on a case of paraganglioma manifesting as enlargement of the lateral rectus muscle. Magnetic resonance imaging (MRI) of the orbit showed typical salt and pepper appearance of the mass and pathologic examination was consistent with paraganglioma. The patient underwent surgery with total removal of lateral rectus muscle. Alignment was preserved by a half tendon transposition of the vertical rectus muscles to the insertion of the resected lateral rectus muscle. Isolated lateral rectus enlargement has not been previously reported as a manifestation of paraganglioma.

Orbital and preseptal cellulitis: a 10-year survey of hospitalized patients in a tertiary eye hospital in Iran.

To evaluate the demographic and clinical features of orbital cellulitis (OC) and preseptal cellulitis (PC) in a tertiary eye hospital over a 10-year period. This is a retrospective study of files of patients defined as OC or PC admitted to Labbafinejad Hospital, Tehran, Iran, in which clinical specificities and results of treatment and complications were reviewed. A total of 93 records of patients with OC or PC were identified from 1997 to 2007. 42 % of the patients had orbital and 58 % had PC. OC was found to be twice as common in males but PC occurred equally in both sexes. The mean ages ± SD of patients with OC and PC were 27.4 ± 23.9 and 19.1 ± 23.3 years, respectively. 97.8 % of involvements were unilateral. The most common complaint of the patients was change in lid appearance and the most common season of involvement was spring in both groups. Sinusitis was the most common background in 53.8 % of OC and 24.1 % of PC patients, and the sinus most commonly involved was the ethmoid. Surgical intervention was needed in 48.7 % of orbital and 14.8 % of PC. The only complication seen in OC was external ophthalmoplegia in a case which needed operation. In our geographical region, orbital and PC are seen most frequently in young patients in spring and their most common background is ethmoiditis; complications may be prevented by appropriate medical and/or surgical management.

Lacrimal gland lymphangioma: report of a case and review of literature.

Herein, we present a patient with acute proptosis and inferonasal displacement of the right eye. CT scan showed heterogeneous enlargement of the right lacrimal gland. During surgical exploration, a dark liquid exuded from the lacrimal gland and histopathology confirmed a diagnosis of lymphangioma. Clinical signs and symptoms improved after surgery and no recurrence occurred up to 2 years of follow-up.

Outcomes of levator resection at tertiary eye care center in Iran: a 10-year experience.

PURPOSE: To assess outcomes of levator resection for the surgical correction of congenital and acquired upper lid ptosis in patients with fair to good levator function and evaluation of the relationship between demographic data and success of this operation. METHODS: In a retrospective study, medical records of patients with blepharoptosis who had undergone levator resection over a 10-year period and were followed for at least 3 months were reviewed. RESULTS: Overall, 136 patients including 60 (44.1%) male and 76 (55.9%) female subjects with a mean age of 20 ± 13.8 years (range, 2 to 80 years) were evaluated, of whom 120 cases (88.2%) had congenital ptosis and the rest had acquired ptosis. The overall success rate after the first operation was 78.7%. The most common complication after the first operation was undercorrection in 26 cases (19.1%), which was more prevalent among young patients (p = 0.06). Lid fissure and margin reflex distance (MRD(1)) also increased after levator resection (p < 0.001). Age, sex, type of ptosis, amblyopia, levator function, MRD(1), lid fissure and spherical equivalent were not predictive of surgical outcomes of levator resection. CONCLUSIONS: Levator resection has a high rate of success and few complications in the surgical treatment of congenital and acquired upper lid ptosis with fair to good levator function. Reoperation can be effective in most cases in which levator resection has been performed.

Oral propranolol for treatment of pediatric capillary hemangiomas.

PURPOSE: To report the long-term results of treatment of pediatric capillary hemangiomas with oral propranolol. METHODS: Three infants, 3 to 4 months of age, with periocular capillary hemangiomas were treated with oral propranolol solution (Inderal, 20mg/5ml) 2-3 mg/kg per day divided in 2 doses. Propranolol was continued up to the end of the first year of life and tapered over 2-3 weeks. All infants were followed for 20 months. Lesion size and evolution were assessed during the follow-up period. RESULTS: Significant improvement was noted in all patients in the first 2 months of therapy with slow and continuous effect throughout the follow-up period. No serious complications were observed. CONCLUSION: Oral propranolol can be used as a first line agent in children with capillary hemangiomas.

Recurrent Orbital Cavernous Hemangioma due to Overlooked Multiple Tumors.

PURPOSE: To report late recurrence of orbital cavernous hemangioma in a patient ten years after complete resection of the primary tumor. CASE REPORT: A 32-year-old woman with a history of progressive visual loss and proptosis underwent lateral orbitotomy for resection of a large cavernous hemangioma. Ten years later, proptosis recurred and the patient developed progressive ocular deviation. Imaging studies were in favor of a recurrent cavernous hemangioma and the tumor was excised via the previous incision site. Reassessment of previous orbital images suggested the presence of two separate tumors, only one of which had been excised at the time of initial surgery. CONCLUSION: Recurrent orbital cavernous hemangioma may follow incomplete excision of multiple orbital lesions with gradual growth of unidentified residual tumors. Accordingly, when an encapsulated cavernous hemangioma is removed, exploration is recommended to rule out multiple lesions.

Successful treatment of orbital hemangioma with propranolol in a 5-year-old girl.

We report a 5-year-old girl, who presented with proptosis due to an orbital capillary hemangioma. After 8 months of treatment with oral propranolol at a dose of 2 mg/kg/day, the mass reduced significantly in size and regrowth was not observed within 20 months of follow-up.

Direct tarsus to frontalis muscle sling without flap creation for correction of blepharoptosis with poor levator function.

PURPOSE: To report the outcomes of ptosis surgery in patients with weak levator function utilizing the direct tarsus to frontalis muscle sling technique without creation of a flap. METHODS: In a prospective nonrandomized case series over a 3-year period, patients with ptosis and weak (less than 4 mm) levator function underwent direct sling of the tarsus to frontalis muscle without creating any flap. Success was defined as upper lid margin to central corneal reflex distance of at least 3 mm in bilateral cases and a difference of less than 1 mm in unilateral cases. RESULTS: Overall, 26 eyes of 22 patients with mean age of 15.4 ± 9.4 years were operated and followed up for 13.5 ± 8.4 months. The ptosis was congenital in 15 patients (68.2%) and acquired in 7 patients (31.8%). Twelve patients (54.5%) had a history of ptosis surgery. The procedure was judged as successful in 77.3% of patients after initial surgery and in 100% after reoperation. Surgical success after initial surgery was directly correlated with the amount of levator function (P = 0.02). However, success was not associated with age (P = 0.9) or history of surgery (P = 0.9). None of the patients developed eyelid hematoma, lagophthalmus or dry eye. CONCLUSIONS: Direct sling of the upper tarsus to the frontalis muscle without creation of flap is an effective procedure for correction of ptosis in patients with weak levator function. Minimal dissection and preservation of the orbicularis oculi prevents lagophthalmus and its consequences.

Globe fixation with homologous temporalis fascia transplant for treatment of restrictive esotropia strabismus: an interventional case report and review of the literature.

PURPOSE: To report a case of fat adherence complication syndrome after pterygium surgery, sufficiently severe enough to create a recurring significant extraocular motility problem and its ultimate novel and successful management. METHOD: A 75 year old man was referred with an acquired large angle esotropia after pterygium surgery. Multiple previous strabismus surgeries to relieve the esotropia had already been performed but failed. Bilateral poor vision obviated complaints of diplopia but his binocular visual field was halved and his vision overall and his motility vision was handicapped by this limited ocular motility in his right eye. We therefore utilized homologous adjacent temporalis fascia transplantation for re-fixation of his frozen esotropic globe in primary position. Result of Surgery: Not only was the esotropia resolved but he also developed and regained some degree of abduction in this eye. CONCLUSION: Homologous Temporalis fascia transplant can be used safely, for globe fixation in surgical treatment of severe restrictive strabismus.

A comparison of argon laser and radiofrequency in trichiasis treatment.

PURPOSE: The aim of this study was to find concrete clinical evidence for determination of the best method of treatment for trichiasis and the location that responds best to treatment with radiofrequency and argon laser. METHODS: This study was performed in 2007 and 2008 on 100 patients, involving a total of 1,181 lashes in contact with the globe. Patients were randomly assigned to 2 groups of treatment: the radiofrequency group (group 1; 2 watts, 2- to 3-mm depth, cut-coagulating mode) and the argon laser group (group 2; spot size 50 µm, 760 mW, 930-nm wavelengths, continuous). After complete ophthalmic examination and photography, the eyelid was divided into 3 segments (medial, central, and lateral) and treated. The patients were examined 3 months later in terms of response to treatment, pain, and complications. RESULTS: The mean age of the patients was 57.1 ± 24, ranging from 14 to 98 years. Of the 100 patients included, 56% were women and 44% were men. The results revealed the successful treatment of 472 (82.4%) lashes in the radiofrequency group and 383 (62.9%) in the argon laser group. Responses were significant in the central regions of the upper and lower lids (p = 0.001). Similarly, notching was observed in 4 cases, 3 of which (75%) belonged to the radiofrequency group. However, this trend was not statistically significant. CONCLUSION: The radiofrequency method was found to be superior in comparison to argon laser in the central regions of both upper and lower eyelids.

Clinicopathological study of lacrimal sac specimens obtained during DCR.

PURPOSE: To determine the histopathologic characteristics of lacrimal sac specimens in adult patients undergoing external dacryocystorhinostomy (DCR) for acquired nasolacrimal duct obstruction. METHODS: A total of 471 lacrimal sac biopsies were obtained from 449 patients undergoing external DCR for symptoms or signs of acquired nasolacrimal duct obstruction and examined histopathologically. RESULTS: A total of 449 subjects including 283 (63%) female and 166 (37%) male subjects with mean age of 50.02 years underwent DCR and histopathologic examination of specimens. Presenting symptoms were epiphora in 411 patients (91%), history of acute dacryocystitis in 17 patients (4%) and obstruction revealed during ophthalmic examinations in 21 patients (5%). Histopathologic findings included: chronic inflammation in 450 patients (95.5%), fibrosis in 18 patients (3.8%), lymphoma in two patients (0.4%) and reactive lymphoid hyperplasia in one patient (0.2%). Lacrimal sac appearance during surgery was grossly abnormal in two cases: one case of lymphoma and one instance of reactive lymphoid hyperplasia. CONCLUSIONS: Chronic inflammation and fibrosis are the most common histopathologic findings in lacrimal sac specimens obtained during DCR. Only two cases of lymphoma (0.4%) were encountered in the series, one of which had a suspicious lacrimal sac appearance during surgery while the other case (0.2% of all specimens) was unsuspected. The rate of malignant etiology for NLD obstruction is low enough to justify lacrimal sac biopsy only in suspicious cases.

Transcutaneous dysport injection for treatment of upper eyelid retraction associated with thyroid eye disease.

PURPOSE: To evaluate the safety and efficacy of transcutaneous injections of botulinum toxin type A (Dysport) in the treatment of upper lid retraction associated with thyroid eye disease (TED). METHODS: A total of 25 eyes of 16 patients including 11 female and 5 male subjects with stable TED condition were enrolled into the study. Mean age was 35.7 years (21-55). A transcutaneous injection of 20U Dysport was administered into each eyelid at the central superior tarsal border, aiming at the levator aponeurosis and Muller muscle. All patients were followed regularly for 4 to 6 months. Any complications, such as ptosis, diplopia, pain, or lid ecchymosis were recorded. RESULTS: All patients experienced considerable reduction of palpebral fissure height. The mean lowering of the lid was 4.24 mm standard deviation (SD) =2.005, 2 weeks after intervention, and the effect remained for a minimum period of 4 months. There were temporary complications such as ptosis, which occurred in 4 patients for 4 weeks. CONCLUSIONS: A single transcutaneous injection of Dysport is safe and effective for treatment of lid retraction due to TED. Minor complications such as ptosis and diplopia may occur, however, this modality may offer temporary relief for patients with dysthyroid lid retraction awaiting orbital decompression or strabismus surgery or both.