Eyelid-Cheek Junction Soft-Tissue Perineurioma: Case Report and Controversies.

Perineurioma is a rare soft-tissue tumor with characteristic histologic and immunohistochemical features. The diagnosis; however, can be met with certain challenges. A 71-year-old woman presented with an enlarging painless mass in the right lower eyelid-cheek junction. The lesion presented as a raised overhanging trunk-shaped mass. An excisional biopsy and local reconstruction were performed. The overall morphology and immunohistochemical findings were most supportive of a cellular soft-tissue perineurioma, with differential diagnoses including dermatofibroma. To the authors' knowledge, this is the first histopathologically reported case of a superficially occurring soft-tissue perineurioma in the eyelid-cheek junction. The authors discuss the presentation, relevant literature, and controversies associated with this diagnosis.

The Role of Postoperative Bandage Contact Lens in Patients Undergoing Fasanella-Servat Ptosis Repair.

PURPOSE: To determine whether a bandage contact lens (BCL) improves patient comfort in the postoperative period in patients undergoing ptosis repair using the Fasanella-Servat technique, compared with no BCL. METHODS: In this prospective, randomized, double-masked, comparison study, all patients had bilateral Fasanella-Servat surgery. A total of 30 patients were randomized to receive a BCL in one eye and no BCL in the other eye. Patient discomfort was measured as the primary outcome using the Eye Sensation Scale. Blurred vision was measured as a secondary outcome using selected questions from the Ocular Surface Disease Index. The surgeries were performed by 2 surgeons (J.T.H and R.S.A). Outcomes were measured one week following the procedure. RESULTS: Patients reported significantly less discomfort in the eye receiving a BCL, with only 13.3% ranking discomfort as "moderate" or "severe," compared with the eye not receiving BCL, where 63.3% of patients rated discomfort as "moderate" or "severe" (p < 0.001). There was no significant difference in patient-reported blurred vision between the 2 groups (p = 0.520). CONCLUSIONS: The use of a bandage contact lens after Fasanella-Servat procedure for ptosis repair is recommended as it improves patient comfort. In addition, it has no detrimental effect on patient-reported blurring of vision.

Conservative therapy for chalazia: is it really effective?

PURPOSE: To assess the within-treatment efficacy of hot compresses (HC), HC plus tobramycin (Tobrex) and HC plus tobramycin/dexamethasone (Tobradex) for chalazia treatment. METHODS: Design: Multicentre, randomized clinical trial (ClinicalTrials.gov identifier, NCT01230593). SETTING: Two clinical sites in New York and two clinical sites in Ontario. STUDY POPULATION: A total of 149 patients with one or more chalazia on separate eyelids randomly assigned to receive HC (n = 50), HC plus tobramycin (n = 50) or HC plus tobramycin/dexamethasone (n = 49). INTERVENTION: 4-6 weeks of assigned treatment. Patients were measured for chalazion horizontal width and surveyed for pain and treatment satisfaction levels. MAIN OUTCOME MEASURES: Primary outcome was complete resolution (100% size reduction). Secondary outcomes were size change in millimetres and patient reported pre- and post-treatment pain and satisfaction levels. RESULTS: In the intention-to-treat (ITT) population, complete resolution occurred in 36 (18%) lesions total, 13 (21%) treated with HC, 12 (16%) with HC plus tobramycin and 11 (18%) with HC plus tobramycin/dexamethasone, with no significant difference between them (p = .78). Individually by paired t-test, there were statistically significant post-treatment mean size differences: HC 1.20 mm (p < 0.001), HC plus tobramycin 1.69 mm (p < .001) and HC plus tobramycin/dexamethasone 1.54 mm (p < 0.001), but no significant difference between them (p = .61). Lesions that completely resolved had a statistically significant lower pretreatment duration (1.5 months) compared to lesions that did not completely resolve (2.2 months) (p = .04). CONCLUSION: Hot compresses (HC) alone or in combination with tobramycin or tobramycin/dexamethasone drops and ointment are all effective first-line treatment options for chalazia. However, physicians may consider moving directly to the use of more invasive therapies, such as incision and curettage or steroid injections, for chalazia that have been present for more than 2 months, as older lesions are less likely to resolve with conservative therapies alone.

Is gastroesophageal reflux disease associated with primary acquired nasolacrimal duct obstruction?

PURPOSE: To determine if patients with primary acquired nasolacrimal duct obstruction (PANDO) have an increased prevalence of gastroesophageal reflux disease (GERD) compared to the general population. METHODS: Cross-sectional case-control study. The Mayo Clinic Reflux Disease Questionnaire (RDQ) is used to help physicians diagnose GERD. The retrospective group consisted of patients who previously had a dacryocystorhinostomy (DCR) over a 4-year period by one surgeon (JTH) at one institution. The prospective group included consecutive patients undergoing DCR over an 8-month period for PANDO. The control group consisted of patients at our institution who did not have complaints related to nasolacrimal duct obstruction (NLDO) or a known history of NLDO. The RDQ score or a previous diagnosis of GERD was recorded for each patient. The prevalence of patients with GERD in each of the groups was compared to that in the control group using the Fisher exact test. RESULTS: Nine (7.7%) of 117 patients in the control group were found to have GERD. Twenty-four of 65 (36.9%) patients in the retrospective cohort were found to have GERD. Twelve of 18 (66.7%) patients in the prospective cohort were found to have GERD. When the prospective and retrospective groups were compared to the control group, the presence of GERD was higher in patients with NLDO (p < .0001). CONCLUSION: Based on the results of this study and compared to the general population, GERD has an increased prevalence in patients with PANDO. GERD may have a role in the development of PANDO.

Clogging evaluation of open graded friction course pavements tested under rainfall and heavy vehicle simulators.

In this study a new procedure is developed to obtain core samples from field sections to assess clogging mechanisms of open graded friction course (OGFC) pavements using X-ray computed tomography (CT) imaging. The approach compared X-ray computed tomography (CT) images taken before and after: (1) rainfall simulations without trafficking to investigate particle-related clogging and (2) full-scale accelerated pavement rutting tests (APT) to investigate deformation related clogging of OGFC layers. Rainfall simulations were performed with runoff water of known total suspended solids (TSS) and particle size distributions (PSDs). Full-scale accelerated rutting tests were performed under controlled temperature and loads. Both investigations were performed for three different OGFC pavements with different layer thicknesses and mix types. The clogging of rutting test sections were also evaluated by comparing the surface permeability measurements performed before and after APT testing. The results of X-ray CT image processing revealed a significant reduction in air-void content of core samples after APT rutting tests. The highest air-void reduction was concentrated at the bottom of the OGFC layers. Permeability measurements also showed a 40%-90% reduction in permeability after APT trafficking. X-ray CT image processing of core samples tested under simulated rainfall showed that air void content reduction is concentrated in the lower part (2-6 mm from the bottom) of the OGFC layers as a result of particle accumulation. Small changes in air void contents were observed in the upper part of the OGFC layers (10-15 mm) while these reductions in air void contents were not significant to cause surface overflow and hence it is expected that the tested OGFC pavements will have sufficient permeability to infiltrate water during most average storm events.

Comparative field permeability measurement of permeable pavements using ASTM C1701 and NCAT permeameter methods.

Fully permeable pavement is gradually gaining support as an alternative best management practice (BMP) for stormwater runoff management. As the use of these pavements increases, a definitive test method is needed to measure hydraulic performance and to evaluate clogging, both for performance studies and for assessment of permeability for construction quality assurance and maintenance needs assessment. Two of the most commonly used permeability measurement tests for porous asphalt and pervious concrete are the National Center for Asphalt Technology (NCAT) permeameter and ASTM C1701, respectively. This study was undertaken to compare measured values for both methods in the field on a variety of permeable pavements used in current practice. The field measurements were performed using six experimental section designs with different permeable pavement surface types including pervious concrete, porous asphalt and permeable interlocking concrete pavers. Multiple measurements were performed at five locations on each pavement test section. The results showed that: (i) silicone gel is a superior sealing material to prevent water leakage compared with conventional plumbing putty; (ii) both methods (NCAT and ASTM) can effectively be used to measure the permeability of all pavement types and the surface material type will not impact the measurement precision; (iii) the permeability values measured with the ASTM method were 50-90% (75% on average) lower than those measured with the NCAT method; (iv) the larger permeameter cylinder diameter used in the ASTM method improved the reliability and reduced the variability of the measured permeability.

A case of orbital involvement in IgG4-related disease.

A 46-year-old male was referred to the Ophthalmology Service for a 7-year history of bilateral proptosis and a presumptive diagnosis of thyroid eye disease. Past medical history was only significant for autoimmune pancreatitis. All laboratory testing including tests of thyroid function were within normal limits. The patient underwent orbital biopsy and was found to have plasma cells containing mainly IgG4 immunoglobulin that was consistent with IgG4-related disease. The patient was treated with oral prednisone and the proptosis resolved within 3 weeks.

Recurrence rates of basal cell carcinoma of the periocular skin: what to do with patients who have positive margins after resection.

OBJECTIVE: To determine the recurrence rates of basal cell carcinoma of the periocular skin in patients who were in the following 3 groups after pathologic analysis: Mohs frozen sections (negative margins); permanent sections with positive tumor margins; and permanent sections with negative tumor margins at the time of primary surgical removal. DESIGN: The study is a retrospective chart review. PARTICIPANTS: We identified 385 patients who underwent surgery for basal cell carcinoma. The surgery was performed by a single surgeon between January 1, 1995 and January 1, 2005. METHODS: The patients were divided into 3 groups: (i) Mohs frozen sections with margins negative for tumor; (ii) permanent sections with margins negative for tumor; (iii) permanent sections with margins positive for tumor. The recurrence rates of basal cell carcinoma were compared. RESULTS: The recurrence-free rate was 92% for the group that had had Mohs frozen-section, 87% for the group that had had permanent sections with negative margins, and 80% for the group that had had permanent sections with positive margins at 170 months follow-up time. We found that the only predictor of recurrence rate was younger age (hazards ratio (HR) = 0.97 95%; CI 0.94, 0.99; p = 0.021). CONCLUSIONS: The results showed a statistically significant difference in the recurrence-free rate in the 3 groups. A minimum of a 3-year follow-up is recommended in patients who have had basal cell carcinomas removed; the average time to recurrence was approximately 3 years.

Success rates of primary probing for congenital nasolacrimal obstruction in children.

PURPOSE: To determine the success rate of nasolacrimal duct probing for the treatment of congenital nasolacrimal duct obstruction and to identify the age at which the success rate decreases. METHODS: Records for probing procedures from 2005 to 2010, over a 56-month period, were reviewed. Successful probing was defined as complete resolution of epiphora 3 months after treatment. Success rates were compared between children <3 years of age and children ≥3 years of age at the time of the procedure. RESULTS: A total of 168 eyes (128 children, mean age 32.2 ± 23.8 months) had undergone a probing procedure, and the overall success rate was 72%. Children aged <36 months had a success rate of 78%; children aged ≥36 months had a success rate of 50%. Multivariate analysis demonstrated that age at the time of procedure was a significant risk factor for failed probing (P = 0.035; OR, 1.67; 95% CI, 1.04-2.69), whereas sex and bilateral surgery were not. CONCLUSIONS: The success rate of primary probing for congenital nasolacrimal duct obstruction was significantly reduced when performed on children ≥3 years of age.

Permeability measurement and scan imaging to assess clogging of pervious concrete pavements in parking lots.

This paper describes a study that used permeability measurement along with physical and hydrological characteristics of 20 pervious concrete pavements in parking lots throughout California. The permeability was measured at five locations: the main entrance, an area with no traffic, and three separate measurements within a parking space at each parking lot. Hydrological and physical site characteristics such as traffic flow, erosion, vegetation cover, sediments accumulation, maintenance practice, presence of cracking, rainfall, and temperature data were also collected for each parking lot. These data were used to perform detailed statistical analysis to determine factors influencing changes in permeability and hence assessing possible cause of clogging. In addition, seven representative core samples were obtained from four different parking lots with permeability ranging from very low to very high. Porosity profiles produced from CT scanning were used to assess the possible nature and extent of clogging. Results showed that there is a large variation in permeability within each parking lot and between different parking lots. In general, the age of the parking lot is the predominant factor influencing the permeability. Statistical analysis revealed that fine sediment (particles less than 38 µm) mass is also an important influencing factor. Other influencing factors with lower significance included number of days with a temperature greater than 30°C and the amount of vegetation next to the parking lot. The combined scanned image analysis and porosity profile of the cores showed that most clogging occurs near the surface of the pavement. While lower porosity generally appeared to be limited to the upper 25 mm, in some core samples evidence of lower porosity was found up to 100mm below the surface.

Indications for orbital imaging by the oculoplastic surgeon.

OBJECTIVE: To determine the indications for ordering orbital imaging and the indications for ordering CT versus MRI by oculoplastic surgeons and to assess the correlation between surgeon's clinical indications for imaging and the radiologist's diagnosis. DESIGN: Retrospective review of imaging requisitions and radiology reports. PARTICIPANTS: Patients of 4 oculoplastic surgeons who required CT or MRI scans. METHODS: Imaging requisitions and radiology reports of patients from 4 oculoplastic surgeons were reviewed to determine the indication for ordering a CT or MRI scan between March 2006 and March 2009. The indications were then compared with the radiologist's diagnosis. RESULTS: A total of 735 patients were included: 449 (61.1%) female and 286 (38.9%) male, with an average age of 50.1 years and an age range of 7 months to 93 years. Of these patients, a total of 632 CT and 223 MRI scans were ordered, 135 of which were follow-up scans. CONCLUSIONS: The most common indication for CT scan was thyroid disease, followed by orbital tumors and then inflammatory disease, while the most common indication for MRI scan was orbital tumors, followed by inflammatory disease and then thyroid disease. CT scans were more commonly ordered than MRI, largely for trauma and to rule out orbital foreign body.

Lymphatic drainage patterns of the human eyelid: assessed by lymphoscintigraphy.

PURPOSE: To describe the lymphatic drainage patterns of the human eyelids. METHODS: Twenty-eight consenting patients who underwent unilateral eyelid surgery at McMaster University between March 2001 and July 2003 had their contralateral eyelids injected with 0.2 ml (0.250 mCi) of Tc 99 m sulphur colloid. The patients were divided into 1 of 5 injection sites of the eyelid, namely upper lateral, upper medial, medial canthus, lower medial, and lower lateral. Lymphoscintigraphy was performed between 2 and 6 hours later with a conventional planar gamma camera. Nodes in the head and neck were identified. In 15 patients, the right eye was injected, and in 13 patients, the left eye was injected. RESULTS: Three patients had no nodes that were identifiable. The remaining 25 patients had at least one node identified. In 11 patients, more than one node was identified. In 18 patients, the preauricular node was most intense and recognized first. Regardless of location on the eyelid, the sentinel node was most commonly the preauricular node. CONCLUSIONS: These results conflict with previously described classic drainage patterns of the eyelid lymphatics. In 72% (18/25) of cases, the first-order sentinel node was the preauricular node, regardless of location of the injection site on the eyelid. Many individuals did not fit the classic drainage patterns.

Solitary fibrous tumor of the orbit: a case series.

PURPOSE: Solitary fibrous tumor (SFT) occurs rarely in the orbit. We present four such cases, representing one of the largest case series reported to date of this rare orbital tumor. METHOD: The four patients ranged from ages 20 to 50, all of whom presented with lid swelling or bulging in the involved eye. All four patients underwent CT scan to confirm the diagnosis of an orbital mass, which was then excised. RESULTS: The tumors of all four specimens contained spindle-shaped cells with bland nuclei and rare mitotic figures. They all stained positively with CD34 and vimentin. Resection margins were positive in two of the four cases. One of these cases demonstrated residual tumor on follow-up CT scan, which remained unchanged at one-year follow-up. No evidence of residual tumor was found in the other three cases, despite one having malignant pathology. CONCLUSION: SFT is a rare and generally benign tumor of the orbit. Immunohistochemical testing with CD34 is necessary to confirm the diagnosis. Although en bloc tumor resection is the definitive treatment, residual tumor may remain stable for some time. However, this must be followed closely if complete resection is not carried out.

Digital photography as a novel technique of measuring ocular surface dimensions.

PURPOSE: To introduce a novel technique for measuring ocular surface dimensions using digital photography and computerized image analysis in the context of ptosis repair surgery. METHODS: Digital photographs and patient questionnaires on dry eye symptoms were obtained from 31 patients before and after ptosis repair. Patients were examined preoperatively and at 1 and 6 weeks postoperatively. Adobe Photoshop 7.0 (Adobe Systems Incorporated, 345 Parkl Avenue, San Jose, CA 95110-2704, USA) was used to digitally measure palpebral fissure height, fissure width, and ocular surface area (OSA). Similar digital measurements were obtained on 30 control subjects as well. Digital calculations of OSA for control, preoperative, and postoperative groups were compared with other published techniques. RESULTS: Graphical comparison between our method of measuring OSA and the mathematical estimations proposed by previous studies suggests that our method is more precise in measuring OSA, and that it is also better able to identify individual variations of OSA from general population trends. CONCLUSION: Digital ocular photography combined with computerized image analysis is a fast, easy to use, and reliable method of measuring ocular surface dimensions. In addition to ptosis surgery, this method can be used in other ocular surface studies.

Fasanella-Servat procedure: indications, efficacy, and complications.

BACKGROUND: The Fasanella-Servat procedure is used for the repair of mild to moderate ptosis. The purpose of this study was to determine the efficacy of the Fasanella-Servat procedure for the repair of several forms of ptosis. METHODS: The authors retrospectively reviewed 169 charts of 2 surgeons from 1988 to 1996. All patients had undergone a Fasanella-Servat procedure for ptosis. Patients with less than a 1-month follow-up were excluded, leaving 153 eyelids of 144 patients. Surgical success was defined as lid symmetry within 0.5 mm or correction of eyelid contour abnormality from previous surgery or trauma. RESULTS: Ptosis was classified as involutional, occurring after intraocular surgery, congenital, due to Horner's syndrome present after levator surgery, and myogenic/other. With a mean follow-up of 7 months, success was achieved in 89.5% of cases (137/153). Among subgroups, success was highest at 100% in Horner's syndrome (8/8) and post-levator surgery (11/11), and lowest in congenital ptosis at 76.4% (13/18). Postoperative problems included dry eye symptoms (6/144 patients), contour abnormalities in 12 lids, and dermatochalasis in 10 lids. INTERPRETATION: The Fasanella-Servat operation is effective for mild to moderate ptosis from a variety of causes and for contour abnormality correction in patients with little or no ptosis. Despite the long-held belief that excision of the accessory lacrimal glands of Wolfring leads to dry eye symptoms, our study found this to be the exception. This procedure has the advantage of high reliability when reasonable preoperative criteria are applied and is minimally invasive.

Congenital orbital and disseminated extrarenal malignant rhabdoid tumor.

A 5-week premature infant boy with tumorous malformations underwent biopsy of two truncal masses and exenteration of the left orbit. Specimens were examined histologically. Histologic reports, slides, and clinical photographs were reviewed. A diagnosis of malignant rhabdoid tumor was made. Malignant rhabdoid tumors can present as local or disseminated neoplastic disease involving the orbit and should be considered in the differential diagnosis of rapidly progressing orbital lesions presenting in early infancy. We review the current classification of rhabdoid tumors and the previous literature on orbital rhabdoid tumors.