Hepatocellular carcinoma metastatic to the orbit.

We report a rare case of orbital metastasis from hepatocellular carcinoma and review previously documented cases of this condition. The clinical, histopathological, and immunohistochemical characteristics of hepatocellular carcinoma metastatic to the orbit are described. Results from histopathological examination and histochemical findings of the orbital mass established the diagnosis. A review of 10 cases of metastatic hepatocellular carcinoma to the eye and orbit disclosed painful proptosis as the most common clinical sign of hepatocellular carcinoma metastatic to the orbit. In 5 (56%) of the 9 cases that had orbital metastasis (including the present case), the diagnosis was made after the patient first was examined with symptoms from the orbital mass. Metastatic hepatocellular carcinoma should be considered as a rare cause of painful proptosis. While patients usually are seen with signs and symptoms of widespread metastatic carcinoma, patients with hepatocellular carcinoma with orbital involvement may be first examined by the ophthalmologist because of the clinical manifestations of the disease, proptosis and pain. Other orbital lesions associated with painful proptosis are discussed briefly.

The effect of phenylephrine on Müller muscle. A blepharogram study of eyelid motion.

PURPOSE: The blepharogram technique is used to study the effect of a drug on blinking. The authors show that ocular instillation of phenylephrine, a stimulant of Müller muscle of the eyelid, accelerates the up phase of the blink. METHODS: Motion of a tiny search coil glued to the eyelid moving in a weak magnetic field modifies an induced alternating current which is amplified and used to display the position of the upper eyelid in degrees on the ordinate of a graph with time in milliseconds on the abscissa. The graph is called a blepharogram. Blepharogram studies and individual blink analysis show the effect of phenylephrine on eyelid motion (blinking). RESULTS: Instillation of phenylephrine accelerated the up phase of the blink in all ten experimental subjects. In 65% of subjects, phenylephrine also produced or increased newly described N and M blepharogram patterns. CONCLUSION: This is the first instrumental detection of the effect of a pharmacologic agent on eyelid motion. The blepharogram technique provides insight into eyelid physiology and can be used to study any neuromuscular condition that affects eyelid motion.

Surgery for upper eyelid retraction, three techniques.

BACKGROUND: This paper is based on the author's experience with 145 operations on 181 upper eyelids in 100 patients using three techniques for recession of the upper eyelid. The results include 15 years' experience with adjustable sutures in upper eyelid recession surgery. METHODS: Each chart was reviewed by the author. Patient data was entered into a database and analyzed. The operations used were (1) The prewhitnall levator recession (Trans Am Ophthalmol Soc. 1988: 86: 725-793). This operation is unique in that it is performed on the levator muscle proximal to Whitnall's ligament. (2) Recession of the levator aponeurosis and (3) the Henderson operation (Arch Ophthalmol 1965; 74: 205-216). Adjustable sutures were used in all prewhitnall recessions, about half of the levator aponeurosis recessions and none of the Henderson operations. RESULTS: Complications were divided between over and undercorrection. There were 24% reoperations in 73 patients with thyroid eye disease and 14% reoperations in 17 patients with overcorrected ptosis. The overall reoperation rate was 23%. Adjustable sutures were effective in prewhitnall recessions but less so in levator aponeurosis recessions. There were fewer Henderson operations but the results were good. CONCLUSIONS: The prewhitnall operation is good for marked bilateral eyelid retraction in thyroid eye disease. It is technically challenging but has advantages. Recession of the levator aponeurosis can be used for thyroid eye disease and overcorrected ptosis. The Henderson operation is useful in lesser degrees of eyelid retraction. The need for reoperation is an acceptable occurrence and can be expected in up to one fourth of patients.

An expansion prosthesis for the microphthalmic socket.

An expansion prosthesis has been developed for the anophthalmic or microphthalmic socket. Orthodontic wire covered with silicone tubing is fused onto a conventional methyl-methacrylate ocular prosthesis. The use of this device is illustrated in a case report.

The tight retracted lower eyelid.

Grave's ophthalmopathy, anophthalmia, trauma, surgery, burns, and skin disorders can result in lower eyelid retraction. The retracted lower eyelid is tight in contrast to the lax lower eyelid of the common involutional ectropion. Cicatrization of the skin and muscle produces the prototype cicatricial ectropion. Downward traction on all layers of the lid rather than cicatrization causes lower eyelid retraction. Sixty-one retracted lower eyelids were surgically repaired without a skin graft in 40 patients. In the new technique, the retracted lower lid is repaired by releasing the lower eyelid retractors from their tarsal attachment. A lateral canthoplasty and lower lid prezygomatic flap anchored to the orbital periosteum support the released lower eyelid.

Enlargement of levator palpebrae superioris muscle fibers in Graves' ophthalmopathy.

Enlargement of the extraocular muscles in Graves' ophthalmopathy is attributed to inflammation and fibrosis. This is the first report of the histology and morphometry of the levator palpebrae superioris (LPS) muscle proximal to Whitnall's ligament in Graves' ophthalmopathy. Four thousand computer-assisted levator muscle fiber measurements in 16 control and abnormal levator palpebrae superioris muscle biopsies were done. These measurements showed statistically significant levator muscle fiber enlargement in the Graves' ophthalmopathy specimens. There was minimal evidence of inflammation. These findings suggest that muscle fiber enlargement is an important cause of the characteristic hypertrophy of the levator muscle in Graves' ophthalmopathy. Levator muscle fiber enlargement is a likely cause of upper eyelid retraction in Graves' ophthalmopathy.

The measurement and definition of ptosis.

Measurements of 242 ptotic and normal eyelids were recorded clinically and compared with algebraically derived measurements from projected 35 mm photographs. Accuracy to 1.5 mm or better was obtained in 84% of clinical as compared with photographic measurements. The following definition is suggested: ptosis is present when the upper eyelid is less than 2 mm from midpupil. Reduction of the upper field of vision to 30 degrees or less is present in 97% of eyes with ptosis so defined. Asymmetric ptosis is present in the lower of the two upper eyelids when there is 2 mm or more asymmetry between the levels of the upper eyelids, even if both eyelids are 2 mm or more from midpupil. Although ptosis is best defined in terms of the midpupil to upper lid distance, the diagnosis of ptosis rests with the examining physician based on the clinical evaluation of the patient.

The use of split-thickness skin grafts for eyelid and facial reconstruction after Mohs' fresh-tissue surgery.

In the last 10 years. Mohs' fresh-tissue surgery has been increasingly employed for the treatment of extensive basal cell carcinomas and other malignancies of the eyelids. Large defects after Mohs' surgery for these lesions may involve the nose, cheek, forehead, and other parts of the face as well as the eyelids, medial canthus, and lacrimal drainage system. Split-thickness skin grafts are useful in repairing these large defects and can be combined with other eyelid procedures such as the Hughes operation for lower-eyelid reconstruction.

Genesis of breast cancer is in the premenopause.

In Britain and other high-risk countries, about a third of patients with breast cancer are premenopausal at diagnosis. In the remainder, tumour initiation might have occurred in the premenopause, even though the clinical presentation was late in life. This possibility has important implications for breast cancer prevention and screening. The relations between the patient's age and tumour kinetics, prognosis, oestrogen receptors, and environmental X-ray carcinogenesis were studied, together with the age-related protection afforded by pregnancy. The findings support the hypothesis that breast cancer is initiated in the premenopause.

Upper eyelid retraction in Graves' ophthalmopathy: a new surgical technique and a study of the abnormal levator muscle.

A new surgical procedure, the proximal levator technique, achieves recession of the retracted upper eyelid in Graves' ophthalmopathy by sectioning the levator muscle proximal to Whitnall's ligament and fixing eyelid position with sutures that permit postoperative adjustment. This technique deserves further study. Enlargement of the proximal levator muscle in Graves' eye disease is shown on orbital CT scans and is found at surgery when the proximal levator technique is employed. Histologic and morphometric studies demonstrate increased levator muscle fiber size as well as increased extracellular volume. These findings suggest that levator muscle hypertrophy is important in the pathogenesis of upper eyelid retraction in Graves' ophthalmopathy.

A new upper blepharoplasty clamp.

New right and left blepharoplasty clamps have been devised which conform to the three-dimensional curves of the adult upper eyelids. These are suggested for use in older patients who require excision of a large amount of skin and are an adjunct in upper blepharoplasty. We have used the new clamps successfully in 20 upper blepharoplasties. The clamps provide for a rapid, bloodless removal of large amounts of skin.