Full-thickness grafting of acute eyelid burns should not be considered taboo.

Split-thickness skin grafts are commonly used for the treatment of acute eyelid burns; in fact, this is dogma for the upper lid. Ectropion, corneal exposure, and repeated grafting are common sequelae, almost the rule. It was hypothesized that for acute eyelid burns, the use of full-thickness skin grafts, which contract less than split-thickness skin grafts, would result in a lower incidence of ectropion with less corneal exposure and fewer recurrences. The records of all patients (n = 18) who underwent primary skin grafting of acutely burned eyelids (n = 50) between 1985 and 1995 were analyzed retrospectively. There were 10 patients who received full-thickness skin grafts (12 upper lids, 8 lower lids) and 8 patients who received split-thickness skin grafts (15 upper lids, 15 lower lids). Three of 10 patients (30 percent) who received full-thickness skin grafts and 7 of 8 patients (88 percent) who received split-thickness skin grafts developed ectropion and required reconstruction of the lids (p = 0.02). No articles were found substantiating the concept that only split-thickness grafts be used for acute eyelid burns. The treatment of acute eyelid burns with full-thickness rather than split-thickness skin grafts results in less ectropion and fewer reconstructive procedures. It should no longer be considered taboo and should be carried out whenever possible and appropriate.

Conjunctival cysts of the orbit.

OBJECTIVE: This study reviews functionally and anatomically disruptive features of simple conjunctival orbital cysts. DESIGN: A case series review from four oculoplastic practices over 6 years. PARTICIPANTS: Eleven patients with simple conjunctival cysts of the orbit were identified. INTERVENTION: All cysts were excised and evaluated histopathologically. MAIN OUTCOME MEASURES: Assessment was made of the length of time from inciting event to presentation, preoperative and postoperative refractive state and ocular motility, the presence or absence of discomfort, and radiographic or clinical evidence of bone remodeling. RESULTS: Six of 11 cysts were presumed to be primary, unrelated to antecedent surgery or trauma. Four of 11 cysts were associated with pain or tenderness, 5 cysts induced ocular motility disturbance, 6 cysts caused observable globe distortion or refractive error change, and 6 cysts remodeled bone. CONCLUSIONS: Simple conjunctival cysts of the orbit, traditionally regarded as low-pressure lesions with minimal structural impact, may induce considerable anatomic and functional disruption.

Orbital decompression for preservation of vision in Graves' ophthalmopathy.

Graves' ophthalmopathy (thyroid eye disease) can result in progressive visual loss. The University of Washington (Seattle) experience in orbital decompression was reviewed for the years 1983 through 1990 to determine overall safety and outcome. Twenty patients underwent transantral decompression of 36 orbits for either steroid therapy failure, steroid therapy intolerance, or recurrence of optic neuropathy with tapering of the steroid therapy. Decompression successfully improved visual function in 33 of the orbits (92%) and a second decompression procedure was successful in another two (5%) of the orbits (6%). There were no major complications or cases of decreased visual function. Diplopia, present preoperatively in 17 patients (85%), was improved in eight patients (47%) and unchanged in nine patients (53%). However, of the three patients without preoperative diplopia (15%), one had development of new-onset diplopia postoperatively. Transantral decompression of the orbit offers a safe and effective therapeutic modality for vision-threatening Graves' ophthalmopathy.

Primary malignant ectomesenchymoma of the orbit.

Malignant ectomesenchymoma (MEM) is a rare soft tissue tumour believed to arise from a pluripotential migratory neural crest cell and composed of both a mesenchymal element (most often rhabdomyosarcoma) and a neuroectodermal element (often neuroblastoma). Reported sites of origin are the abdomen, perineum or scrotum, the extremities, the middle ear, nasopharynx, face, and neck. We report the first case of an orbital MEM, with a review of the 17 cases previously reported from other sites.

Oncocytoma of the caruncle.

Oncocytomas of the ocular adnexa are rare, but when they occur, are most commonly located on the caruncle. Oncocytic carcinomas have been reported but the majority of caruncular oncocytomas are benign. The lesions present as small, cystic, tan-to-red lesions. Histologically, the oncocytes are arranged in an adenomatous pattern. The cells have central nucleoli surrounded by eosinophilic cytoplasm. Electron microscopically, the cytoplasm is filled with mitochondria. As the packing of mitochondria increases, the nucleoli become eccentric and pyknotic, possibly suggesting an end-stage process. A typical clinical case is presented.

Asymptomatic orbital cavernous hemangiomas.

Computed tomographic (CT) scanning and magnetic resonance imaging (MRI) are commonly performed to evaluate neurologic symptoms. Rarely are asymptomatic orbital tumors discovered, creating uncertainty about their management. Eleven patients are presented who were referred for asymptomatic orbital tumors discovered on either CT scanning or MRI performed for unrelated symptoms of headache, vertigo, peripheral numbness, seizures, stroke, or hallucinations. The asymptomatic orbital tumors were diagnosed clinically and radiologically as cavernous hemangiomas. All the patients were followed clinically and neuroradiologically for an average of 37 months (range, 8 to 120 months). None of the tumors enlarged during this time. The authors conclude that patients who have asymptomatic cavernous hemangiomas, discovered by coincidence during neuroimaging, that bear no relation to the indication for obtaining the CT scan or MRI, can be safely followed by observation as an alternative to surgical excision.

Endoscopic repair of failed dacryocystorhinostomy.

Primary dacryocystorhinostomy (DCR) failure is commonly due to scarring at the rhinostomy site. Nasolacrimal duct obstruction due to scarring may also occur in patients who have had their lacrimal bone removed during maxillary sinus surgery. Five patients following DCR and 3 patients after sinus surgery, all with constant epiphora, underwent endoscopic reconstruction of their lacrimal drainage system. Preoperatively, patency of the bony ostium was determined either by computed tomographic (CT) scan or dacryocystography. Endoscopically, the lacrimal drainage system was reopened then intubated with a silastic stent. Any scar tissue was visualized endoscopically and resected. Seven of the 8 patients have been followed from 3 to 24 months after stent removal, and all have had relief of their epiphora. Endoscopic repair is a useful adjunct in the management of patients with DCR failure or patients with epiphora after removal of the lacrimal bone during sinus surgery. This brief procedure can be performed under local anesthesia, does not require a skin incision, and allows the evaluation and correction of intranasal pathology.

Orbital mucormycosis with retinal and ciliary artery occlusions.

A 61-year-old man presented with acute, painful loss of vision in the left eye due to a central retinal artery occlusion. Fluorescein angiography confirmed the central retinal artery occlusion and also identified a nasal posterior ciliary artery occlusion. CT scanning revealed a left medial orbital mass with adjacent ethmoid sinusitis. Transnasal ethmoid biopsy disclosed mucormycosis. A left external ethmoidectomy, maxillectomy, and orbital exploration were performed, after which the patient was treated with daily intravenous amphotericin B for six weeks. Coexistence of retinal and nasal posterior ciliary artery occlusion due to mucormycosis may relate to their common origin from the ophthalmic artery. Treatment without exenteration was successful.

Standardized intravitreal injections: evaluation of the effect of anesthesia on rapid axonal transport in the optic nerve.

Retinal ganglion cells incorporate intravitreally injected [3H]leucine into proteins that are transported orthogradely in optic axons to the superior colliculus. Since optic projections in the albino rabbit are nearly totally crossed, an agent suspected to alter axonal transport can be applied to one optic nerve after bilateral intravitreal injection of [3H]leucine; any reduction in radioactivity transported to the contralateral superior colliculus can then be quantified. Such studies require symmetric uptake and incorporation of precursor into ganglion cell proteins. A technique is described for intravitreal injections that reproducibly produces symmetric uptake of [3H]leucine. Using this technique, we determined that retrobulbar injected lidocaine in clinically used doses (2-4%) does not affect rapid axonal transport, while colchicine (a known inhibitor of axonal transport) blocks transport in a dose-related fashion.

Melanoma metastatic to the orbit.

Cutaneous malignant melanoma often metastasizes to the lung, bone, liver, subcutaneous tissue, and lymph nodes. Six cases of malignant melanoma metastatic to the orbit are presented, five from cutaneous melanomas and one from a contralateral choroidal melanoma. Melanoma rarely metastasizes to the orbit, but when orbital involvement occurs, widespread metastases are already present. Twenty-two cases were reviewed from the literature; 13 of 14 patients, with sufficient follow-up data, had widespread metastases when they presented with orbital disease. Extraocular muscles appear to be a favored site of metastases. The mean time from orbital presentation to death was 4 months. Orbital metastases from a distant melanoma is, therefore, part of a widespread metastatic process. Treatment should be directed toward palliation.

Monoclonal antibodies to intermediate filament proteins: diagnostic specificity in orbital pathology.

Intermediate filaments derived from different cell types are antigenically distinct. Monoclonal antibodies to human intermediate filament proteins can, therefore, be used as tissue-specific reagents capable of distinguishing cell type in poorly differentiated neoplasms. We report a case demonstrating the specificity of antiintermediate filament protein antibodies in establishing a difficult orbital diagnosis of esthesioneuroblastoma.

Gaze-evoked amaurosis.

Gaze-evoked amaurosis is a transient monocular loss of vision occurring in a particular direction of eccentric gaze. Six cases are reported with a mean follow-up of 5 years; three with optic nerve sheath meningiomas and three with orbital cavernous hemangiomas. Five of the six patients have had no visual deterioration during follow-up. Bilateral optic nerve sheath meningiomas led to visual deterioration in both eyes of one patient, but gaze-evoked amaurosis was present in only one eye. The symptom of gaze-evoked amaurosis, while alarming, is not predictive of permanent visual loss. Possible mechanisms for gaze-evoked amaurosis include inhibition of axonal impulses or transient optic nerve ischemia.

Diagnosis of orbital and periorbital tumors. Use of monoclonal antibodies to cytoplasmic antigens (intermediate filaments).

Histopathology provides a definitive diagnosis in the majority of orbital and periorbital tumor biopsies. Occasionally, a tumor cannot be diagnosed by conventional histopathologic means, or the diagnosis is suspect. Special stains have been the primary diagnostic alternative in the past; more recently they have been supplemented with electron microscopy. Immunocytochemistry, classification using monoclonal antibodies to specific cellular antigens, has added a new modality to pathologic diagnosis. Immunocytochemistry can aid in diagnosis in three ways: (a) suggestion of a firm diagnosis, (b) selection from a histopathologic differential, or (c) direction for further evaluation such as special stains or electron microscopy. Immunocytochemistry rarely provides a definitive diagnosis but instead confirms the histopathologic diagnosis. Intermediate filaments are cytoplasmic antigens to which monoclonal antibodies are available. Five antigenically distinct groups of intermediate filaments can help classify tumors derived from mesenchymal, muscle, epithelial, glial, or neural cells. Six cases of orbital or periorbital tumors are presented, which demonstrate the usefulness of intermediate filament immunocytochemistry for classification or confirmation of a histopathologic diagnosis.

Orbital osteoma in Gardner's syndrome.

A 30-year-old woman developed proptosis secondary to a left ethmoidal compact osteoma. At age 29 years, a mandibular eburnated (ivory) osteoma was excised. At age 25 years, multiple adenomatous polyps of the colon were resected. Her father, age 61 years, had multiple intestinal polyps and bilateral mandibular osteoma. A 24-year-old sister had an osteoma of the forehead. Gardner's syndrome is an autosomal dominantly inherited disorder characterized by intestinal polyposis, various skin and soft tissue tumors, and osteomas of the bony skeleton. Orbital osteomas occur rarely.