Catastrophic antiphospholipid antibody syndrome manifesting as an orbital ischemic syndrome.

Painful bilateral ophthalmoparesis, marked proptosis, increased intraocular pressure, and blindness developed in a 29-year-old woman with protein C deficiency and catastrophic antiphospholipid syndrome. Magnetic resonance imaging of the orbits showed bilateral proptosis, globe tenting, and tethering of the optic nerves consistent with an orbital ischemic syndrome. Despite aggressive therapy for antiphospholipid syndrome, the patient died. The autopsy showed necrosis of orbital tissues. This is the first report of orbital ischemic syndrome from protein C deficiency and antiphospholipid syndrome.

Chronic exposure keratopathy complicating surgical correction of ptosis in patients with chronic progressive external ophthalmoplegia.

PURPOSE: To report chronic exposure keratopathy related to surgical ptosis correction in patients with chronic, progressive, external ophthalmoplegia. METHODS: Case reports of three patients with chronic exposure keratopathy following blepharoptosis surgery. RESULTS: We report three patients with chronic progressive external ophthalmoplegia with chronic corneal complications after surgical ptosis repair. All three gave a history of blepharoptosis and extraocular muscle dysfunction. Each presented with chronic corneal ulceration. All had histories suggestive of ophthalmoplegia. Treatment of corneal ulceration necessitated hospitalization and surgical intervention. CONCLUSION: Patients with chronic, progressive, external ophthalmoplegia have little ability to properly protect the eye from exposure and are at risk for corneal damage. A thorough ophthalmic history and examination before ptosis surgery may prevent the corneal complications resulting from surgical intervention.

Brown recluse spider bite to the eyelid.

PURPOSE: To present a photographically documented case of a known brown recluse spider bite to the eyelid. DESIGN: Interventional case report. METHODS: The wound was photographed daily during an 11-day hospitalization and at 1 month and 6 months after the injury. Treatment included canthotomy and cantholysis; administration of dapsone, antibiotics, and steroids; and hyperbaric oxygen therapy. MAIN OUTCOME MEASURES: Clinical presentation and course of a known brown recluse spider bite. RESULTS: Complete recovery with cicatrization at the site of the bite. CONCLUSIONS: We present a case of a brown recluse spider bite to the left lower eyelid with a discussion of management and outcome of this rarely reported injury.

Lacrimal disease.

The lacrimal gland has been investigated by a number of authors with specific interest in the relationship between keratitis sicca and systemic disease. Neoplastic involvement of the lacrimal gland and lacrimal sac have drawn the attention of others. Imaging of the lacrimal drainage system by ultrasonography, computerized axial tomography, and magnetic resonance imaging has been reviewed. Finally, surgical approaches to dacryocystorhinostomy and attendant complications have been studied.

Simplified method of sizing implants for orbital fracture repair.

PURPOSE/METHODS: Over the past six years, we have used ordinary radiographic film as a template for sizing alloplastic implants for orbital fracture repair in over 60 patients. The implants are made of such materials as titanium, Vitallium, and porous high-density polyethylene. Autoclaved 9.5 x 4.5-cm rectangles of radiographic film are easily trimmed, held by nontoothed forceps, inserted, and removed from the orbital cavity. RESULTS/CONCLUSIONS: We have found this simple and inexpensive technique to be superior to using aluminum templates that are supplied in commercially available plating sets.

Management of orbital and periorbital arteriovenous malformations.

Arteriovenous malformations (AVMs) of the orbit are progressively enlarging communications between arteries and veins that bypass normal capillary beds. In contrast to arteriovenous fistulas (AVFs), AVMs are congenital lesions with multiple large feeding arteries, a central nidus, and numerous dilated draining veins. Management of AVMs of the orbit may be difficult due to the threat of hemorrhage, vascular occlusion during treatment, and collateral damage to surrounding organs. We managed AVM of the orbit and periorbital tissues in four patients. Neuroimaging studies, clinical decision making, operative experience, and long-term postoperative results were retrospectively reviewed. Four cases of AVM of the orbit and periorbital tissues were successfully treated with preoperative embolization and subsequent excision of the central nidus of the AVM. There was no evidence of recurrence in any of the cases over follow up ranging from 2 to 5 years. We conclude that identification of all arterial feeders, from both internal and external carotid systems, is critical in developing a therapeutic plan. AVMs may be treated by surgical excision alone, or embolization alone. However, in the hands of an experienced interventional neuroradiologist and an appropriately chosen surgical team, most AVMs can and should be treated by a combined approach of preoperative embolization followed by surgical excision of the vascular mass. The goal of therapy is closure of the low-resistance shunt.

Miniplate reconstruction of the lateral orbital rim after orbital decompression for Graves disease.

BACKGROUND: Removal of lateral orbital bone with or without simultaneous removal of the lateral orbital rim is an accepted method of orbital decompression for Graves disease. Once removed, the bone is no longer available for reconstruction and secondary complications such as rounding of the canthal angle, canthal dystopia, and globe dystopia may result. METHODS: The authors replaced the excised bone with a titanium miniplate to protect the globe and fixate the lateral canthal tendon in 18 patients (33 orbits). The orbital rim and lateral orbital wall were completely removed, and the inner aspect of the orbit was enlarged with a cutting burr. A standard titanium miniplate was then anchored to remaining bone, and soft tissue was secured to the miniplate to reconstruct the lateral canthus. RESULTS: The results, as manifest by appearance of the lateral canthus and position of the eyelid in apposition to the globe, were graded as excellent in all patients and orbits. There were no early or late complications. CONCLUSION: Miniplate reconstruction of the lateral orbital rim after decompression for Graves disease allows the beneficial affect of lateral decompression and preserves the functional aspect of the lateral orbital wall.

Results of buccal mucosal grafting for patients with medically controlled ocular cicatricial pemphigoid.

Eyelid surgery for patients with ocular cicatricial pemphigoid is risky when there is unchecked perioperative inflammation. The authors performed buccal mucosal grafts on 42 eyelids (23 eyes) of 17 patients with ocular cicatricial pemphigoid whose disease was controlled by systemic immunosuppression. Results were graded as: improved (12 cases, 16 eyes); satisfactory (2 cases, 2 eyes); or poor (5 patients, 5 eyes). Complications included breakthrough trichiasis, surface keratinization of the graft, blepharoptosis, phimosis, depressed eyelid blink, incomplete eyelid closure, submucosal abscess formation, and persistent nonhealing epithelial defects of the cornea. Technical errors at surgery accounted for two complications. Secondary corneal ulceration developed in two patients. The immunologic aspect of the disease flared or progressed in five patients in the postoperative period and necessitated an increase or change in systemic medication for immunosuppression. Buccal mucosal grafting shows promise in temporarily rehabilitating eyelids of some ocular cicatricial pemphigoid patients whose disease is controlled by immunosuppressive therapy.

Operative complications of the transconjunctival inferior fornix approach.

The transconjunctival inferior fornix incision provides access to the floor, rim, lateral, and inferior medial walls of the orbit. Complications of this surgical approach to the orbit are known to be rare but heretofore have not been clearly defined. Over an 8-year period, in an estimated 1200 cases, the authors have encountered cicatricial entropion, lower eyelid retraction, canthal dehiscence, lower eyelid avulsion, canalicular laceration, buttonhole laceration of the lower eyelid, conjunctival chemosis, and lacrimal sac laceration. Attention to anatomic landmarks and sound surgical execution will prevent these complications in most patients.

Isolated fractures of the orbital floor: risk of infection and the role of antibiotic prophylaxis.

The application of antibiotic prophylaxis to fractures of the orbital floor is controversial. The incidence of infection following this injury remains undefined. We report a case of orbital cellulitis following orbital floor fracture, and attempt to define guidelines for the appropriate use of antibiotics in the setting of an isolated blowout fracture.

Enophthalmos and upper eyelid retraction following osteoplastic frontal sinusotomy.

A 38-year-old man presented with hyperophthalmia, enophthalmos, and upper eyelid retraction 18 months following an osteoplastic flap and frontal sinus obliteration for mucocele. Computerized tomography confirmed the presence of frontal bone absorption in the roof of the orbit with traction and elevation of the orbital contents into the obliterated frontal sinus. A fracture of the orbital roof with penetration of periorbita at the time of original surgery was the suspected precipitating cause of the complication. Surgical management included lysis of the cicatrix between the orbit and frontal sinus and interposition of a silicone sheet between the orbit and sinus, which restored the appropriate anatomic relationships and prevented recurrence.

Giant ovarian cyst: case report and review of differential diagnosis in adolescents.

Ovarian cysts are relatively common in the adolescent, but cystic neoplasms of epithelial origin are seen infrequently. The case is presented of a 15-year-old female with an ovarian serous cystadenoma-the largest such ovarian cyst reported in this age group. The differential diagnosis of ovarian cysts in adolescents is reviewed.