Infantile ulcerative keratitis secondary to congenital entropion.

Congenital entropion is a rare eyelid anomaly that can cause chronic corneal erosions or ulceration. The diagnosis may be easily overlooked by both the pediatrician and the ophthalmologist, particularly when the lids are tightly closed in the crying child. We present three cases of congenital entropion associated with corneal ulceration. Each patient underwent a complete ophthalmologic examination. Examination under anesthesia, including corneal scrapings for culture and photography, was performed before surgical repair of the entropion. There were two cases of lower lid entropion and one case of upper lid entropion. In all three cases symptoms were present since birth, and the diagnosis was overlooked by the treating pediatrician. Corneal ulceration ultimately developed in all three cases. Cultures revealed Staphylococcus aureus in one case, and coagulase negative Staphylococcus in another case. Cultures were negative in one case. In all three patients the ulcers healed rapidly after surgical entropion repair. Congenital upper or lower lid entropion is an uncommon condition that does not spontaneously improve and is an important cause of corneal ulceration in infants. Recognition of this condition is often difficult, and early surgical intervention to repair the lid deformity may help to avoid permanent corneal scarring and visual loss.

Glandular tumors of the lacrimal sac. Their histopathologic patterns and possible origins.

PURPOSE: To describe and characterize the primary lacrimal sac epithelial tumors of glandular origin, and to describe their possible source from glands in the lacrimal sac and nasolacrimal duct walls. METHODS: The authors conducted a clinicopathologic study on 14 patients with epithelial lacrimal sac tumors of possible glandular origin. In addition, they reviewed 35 surgical specimens of the lacrimal sac and nasolacrimal duct region and 13 cadaver specimens of the lacrimal sac region. RESULTS: Six of the tumors were benign: four were oncocytomas and two were pleomorphic adenomas. Eight of the tumors were malignant: three were oncocytic adenocarcinomas, three were adenoid cystic carcinomas, and two were adenocarcinomas. All tumors were from adults, ranging in age from 38 to 87 years. Twenty-eight of the 47 specimens of lacrimal sac and nasolacrimal duct region showed mixed glands of serous and mucous elements. CONCLUSIONS: Although rare, benign and malignant glandular lacrimal sac tumors should be considered in the differential diagnosis of lacrimal sac obstruction. Their possible origin is from the normal glands that exist under the lacrimal sac and nasolacrimal duct epithelium.

Lacrimal sac tumors.

This is a clinicopathologic study of 115 lacrimal sac neoplasms in adults (mean 52 years). The most common presenting signs and symptoms were epiphora (53%), recurrent dacryocystitis (38%), and/or lacrimal sac mass (36%). The tumors were divided into epithelial (82 cases) and nonepithelial (33 cases) neoplasms. Benign epithelial tumors included squamous and transitional cell papillomas (32), oncocytomas (4), and benign mixed tumors (2). The malignant epithelial neoplasms included squamous cell carcinoma (22), transitional cell carcinoma (5), adenocarcinoma (4), mucoepidermoid (3), adenoid cystic (3), and poorly differentiated carcinoma (1). The nonepithelial tumors consisted of fibrous histiocytoma (13), lymphoid lesions (10), malignant melanoma (6), hemangiopericytoma (1), lipoma (1), granulocytic sarcoma (1), and neurofibroma (1). Review of the literature, including our own series, discloses a 55% malignancy rate for tumors originating in the lacrimal sac. Malignant epithelial neoplasms, especially invasive transitional cell carcinoma, often recur locally and can metastasize and be fatal. Epithelial malignancies tend to grow along the epithelium of the lacrimal drainage system, and thus cure is dependent on a wide surgical excision of the tumor and of the entire lacrimal drainage system (canaliculi, sac, and nasolacrimal duct) combined with a lateral rhinostomy and radiation therapy.

Ocular motility disorders secondary to sinus surgery.

Sinus surgery has multiple potential ocular complications including visual loss, diplopia, infection, hemorrhage, and epiphora. We report six patients with ocular motility problems secondary to sinus surgery, review the literature on ocular motility disorders secondary to sinus surgery, and propose an approach for management of those ocular motility problems following sinus surgery. Intranasal sinus surgery was found to be the most common procedure resulting in injury to an extraocular muscle and the ethmoid sinus the most common structure being operated on when injury occurred. The medial rectus was the muscle most commonly injured and it had the poorest prognosis for recovery of functional vision free of diplopia. Optimal timing for repair depends on the structure injured, but early recognition and management appear to be a key to the best outcome for these injuries.

Pediatric orbital tumors.

The proper management of orbital tumors in children requires a knowledge of the lesions commonly seen in this area, in addition to the appropriate methods of investigation and treatment. A multidisciplinary approach is most beneficial in obtaining the desired results.

Herpetic canalicular obstruction.

The viruses of primary herpes simplex, herpes zoster, chicken pox, and vaccinia may produce inflammatory changes in the epithelial lining of the lacrimal canaliculi, resulting in varying degrees of obstruction. Five cases are described and compared with previously reported cases. A review of the literature suggests that the association of ocular viral infections and canalicular complications may be more prevalent than previously suspected. The possible important role of antiviral agents is considered. Early recognition and intubation can often prevent permanent canalicular obstruction, but late cases may require the Jones tube procedure, conjunctivodacryocystorhinostomy.

Breast carcinoma metastatic to the orbit.

Breast carcinoma metastatic to the orbit presented in four patients as a diffuse mass lesion. Clinical findings included restricted ocular motility, palpable mass, enophthalmos, and ptosis. The delay in diagnosis in three cases was due to subtle early findings, the long time interval from the primary breast lesion, lack of other metastases, and, in each of the four cases, the patient's reluctance to disclose any history of breast disease. Pathologic examination of the orbital breast metastases revealed two types: an adenocarcinomatous pattern with nests of pleomorphic malignant appearing cells and a histiocytoid variant with bland, large cells similar to histiocytes.

The histopathology of involutional ectropion.

Twenty eyelid specimens from patients with involutional ectropion, obtained by full-thickness horizontal shortening procedures, were examined histopathologically by light and electron microscopy and compared with six normal eyelids from exenteration specimens. Paralytic, cicatricial, and congenital ectropions were excluded from the study. The main histopathologic features included: (1) collagen degeneration and elastosis of the tarsal plate; (2) increased amounts of adipose tissue in the distal tarsus and capsulopalpebral fascia; (3) subacute inflammation and epidermidalization of the tarsal conjunctiva; (4) focal degeneration, fibrosis and elastosis of pretarsal orbicularis, and occasionally minimal change in the muscle of Riolan; and (5) arteriosclerosis of the marginal artery. The combination of these histopathologic changes characterize and may contribute to the development of ectropion of the eyelid associated with aging.

Sclerochorioretinal resection for choroidal melanoma. A clinicopathologic correlation of a postmortem eye.

A 51-year-old patient underwent a technically successful sclerochorioretinal resection with scleral graft for a medium-sized choroidal melanoma, which proved to be of mixed cell type. Though there was complete resection of the tumor and a favorable visual result, the patient developed metastatic melanoma and died 42 months after the original diagnosis and 34 months after the surgical procedure. Postmortem examination of the involved eye demonstrated excellent anatomic preservation of intraocular structures. Of particular interest was the lack of ischemic necrosis in the anterior segment in spite of surgical disinsertion of two rectus muscles and the ablation of the medial long ciliary artery.