Tarsal switch procedure for the surgical rehabilitation of the eyelid and socket deficiencies of the anophthalmic socket.

PURPOSE: To describe a tarsal transfer procedure, which we have named the "tarsal switch," to correct the eyelid malpositions and camouflage the socket defects of acquired anophthalmos. METHODS: The technique consists of an upper eyelid tarsectomy, with transfer of the autologous tarsoconjunctival graft to the posterior lamella of the lower eyelid. RESULTS: The operation was performed in 21 anophthalmic patients. In 16 patients with eyelid malpositions, excellent results (within 1 mm of the fellow eye) were attained in 100% of the patients with ptosis, and in 88% of patients with lower eyelid retraction. In the remaining 5 patients, orbital volume loss with secondary implant migration, inferior prosthetic displacement and eyelid asymmetry predominated. In these patients the anophthalmic orbital defects and eyelid asymmetry were masked well. Patient satisfaction was high and complications were few during an average follow-up interval of 16 months. CONCLUSION: The tarsal switch procedure is useful in managing the eyelid malpositions and masking the orbital deficiencies of the anophthalmic socket.

Sclerosing sweat duct carcinoma of the eyelid margin: unusual presentation of a rare tumor.

OBJECTIVE: Sclerosing sweat duct carcinoma (SSDC) is a rare, slow-growing, locally invasive skin tumor of eccrine and pilar origin. It is usually located on the face, particularly the upper lip, cheek, and forehead. It has been infrequently reported on the eyelid, secondarily involved from adjacent cheek and brow tumors. Only four previous cases have reported primary eyelid tumors. The authors present four cases of primary eyelid margin involvement, which show the variability in clinical presentations. DESIGN: Retrospective case series. The authors present four case studies of lower eyelid margin tumors diagnosed as SSDC. PARTICIPANTS/METHODS: The history of this recently recognized neoplasm is discussed in relation to the cases presented and the role of the ophthalmologist and pathologist in such cases. RESULTS: Primary SSDC of the eyelid margin is a reportedly rare entity. This particular presentation can occur in all age groups; can mimic benign, acanthotic, or basal cell-like tumors; and is usually misdiagnosed initially. This can lead to a delay in definitive treatment for a tumor that classically presents late in its natural history to health professionals. All eight cases of primary eyelid SSDC now reported in the literature have occurred in the lower lid. CONCLUSION: This rare but aggressive tumor is difficult to diagnose from a simple biopsy and may be more common than previously believed. Initial or early diagnosis is important because of unusually invasive characteristics. Recurrence is common and usually leads to extensive tissue loss via direct invasion or subsequent wide resection. Correct histologic diagnosis at the time of initial tumor removal will likely aid in achieving complete excision with fewer recurrences.

Pseudomonal eyelid necrosis: clinical characteristics and review of the literature.

Pseudomonal eyelid necrosis is a rare condition that has not been well characterized. Five case reports have been previously described. The authors present an additional case, describe its unique features, review the previous reports, and establish the clinical characteristics of the disorder. Pseudomonal eyelid necrosis always occurs in the setting of neutropenia. It may be unilateral or bilateral, and is managed with wound debridement, intravenous and local antibiotics, and, most important, restoration of the neutrophil count. A delay in diagnosis and treatment may lead to functional impairment and cosmetic disfigurement. Although not previously reported in association with eyelid necrosis, uncorrected neutropenia in association with pseudomonal soft tissue infection elsewhere in the body has been associated with septicemia and death. Familiarization with the salient features of the disorder allows prompt therapeutic intervention and may prevent potentially serious complications.

Infantile myofibromatosis of orbital bone. A case report with computed tomography, magnetic resonance imaging, and histologic findings.

OBJECTIVE: The authors report the clinical, radiographic, histologic, and surgical findings of a rare presentation of infantile myofibromatosis. A mass presenting at the inferolateral orbital rim of a 4-year-old child was imaged with both computed tomography (CT) and magnetic resonance imaging (MRI), excised surgically and analyzed histologically to confirm the diagnosis. Infantile myofibromatosis is a rare benign disorder of childhood consisting of well-demarcated nonencapsulated tumors. The overall prognosis depends on the number and location of tumors. Isolated infantile myofibromatosis of the head and neck is the most common form of this generally benign disease. DESIGN: A case review study is presented and discussed with regard to clinical, radiographic, histologic, and interventional findings. The literature is reviewed and the clinical relevance discussed. INTERVENTION: Surgical extirpation of the tumor was undertaken after sufficient localizing radiographic information was obtained. RESULTS: The tumor showed erosion of the orbital bone and orbital extension with reactive hyperostosis on CT imaging. The MRI finding showed an inhomogeneous well-demarcated dark mass on T1 images with increased signal intensity on T2 images. Gadolinium contrast showed significant vascular enhancement. Histologic sections showed a spindle-cell tumor of whorled myofibroblasts surrounding a hemangiopericytoma-like center. The tumor was excised completely. There has been no evidence of recurrence or adverse ocular sequelae in the first 6 months after surgery. CONCLUSIONS: Cases involving the orbit or cranial bones are particularly rare but can have profound secondary effects on local structures. Isolated tumors can occur in all age groups and can mimic more aggressive or malignant neoplasms. The CT and MRI findings are beneficial in establishing a differential diagnosis, plan of treatment, and prognosis. Early diagnosis is important to rule out other neoplasms. The appropriate treatment is excisional biopsy whenever possible and is considered curative. The authors present what to our knowledge is the first reported case of an isolated infantile myofibroma involving an orbital bone.

Intravascular papillary endothelial hyperplasia: collection of four cases and a review of the literature.

Intravascular papillary endothelial hyperplasia is a benign tumor that rarely presents in the orbit and ocular adnexa. Generally, it occurs as an isolated eyelid mass, not associated with systemic or local disease. Histopathologically, it can be easily confused with angiosarcoma or Kimura's disease. We present our experience with four cases of this tumor in the ocular adnexa, along with a literature review.

Military ophthalmology in the Vietnam War.

This overview of the practice of military ophthalmology by US army ophthalmologists during the Vietnam War focuses on administrative management of eye and adnexal injuries, care of the wounded military and of Vietnamese civilians, and research activities. It concludes with improvements that have been subsequently adopted.

Itraconazole in the treatment of orbital aspergillosis.

BACKGROUND: Sino-orbital aspergillosis is typically treated with surgical debridement and intravenous amphotericin B. Some authors have advocated intraorbital irrigation or injection of amphotericin B in specific cases. METHODS: An immunocompetent patient with recurrent sino-orbital aspergillosis is presented. After failing two attempts at traditional therapeutic modalities, treatment with oral itraconazole was initiated. RESULTS: The patient has had resolution of her sino-orbital disease without recurrence at 10 months of follow-up. CONCLUSION: In immunocompetent patients with orbital aspergillosis, itraconazole should be considered as a treatment option in patients who have recurrent or recalcitrant disease, or in those who cannot tolerate amphotericin B.

Clinical and computed tomographic characteristics of amyloid tumor of the lacrimal gland.

BACKGROUND: Lacrimal gland masses, whose soft-tissue contour analysis, on computed tomographic (CT) scanning, shows molding to surrounding orbital structures, include inflammatory and lymphoproliferative lesions. The authors present a patient with orbital amyloidosis isolated to the lacrimal gland who also demonstrates this specific CT presentation. In addition, the literature on this rare condition is reviewed, and characterization of the typical presentation is provided. METHODS: A retrospective review of the four previously reported patients and the authors' additional patient with amyloid tumor of the lacrimal gland was performed. A summary of the clinical characteristics of the disorder was formulated. Special attention was given to to the unique CT findings of the authors' patient. RESULTS: Five patients with amyloid tumor of the lacrimal gland have been described. All patients have been women, with average age of 53 years, and who had the primary, localized variant of the disease. Neither visual impairment nor evidence of optic nerve dysfunction has developed in any of the patients. In the authors' patient, the CT soft-tissue contour analysis of the lacrimal gland mass demonstrated molding to adjacent orbital tissues. CONCLUSIONS: Amyloidosis of the lacrimal gland presents as a primary, localized disease process. It typically affects middle-aged women without visual morbidity. The early CT findings may mimic those seen in inflammatory or lymphoproliferative disorders of the lacrimal gland.

Mucinous eccrine carcinoma of the eyelid.

A 78-year-old woman with recurrent chalazia of the upper eyelid was found to have mucinous eccrine carcinoma. This rare pathologic entity, with low metastatic potential, nevertheless has a significant recurrence rate. This case underscores the importance of considering this tumor in recalcitrant eyelid lesions and highlights the pathology of this tumor. A summary of previous cases is also presented.

Diplopia after surgical repair of orbital floor fractures.

Blowout fractures of the orbit are common sequelae to blunt facial trauma. Many aspects of this injury have been studied, in particular, the timing of and indications for surgical intervention. Although diplopia is often an indication for surgery and is presented to patients as a potential postoperative complication, the incidence of diplopia after surgical repair of orbital blowout fractures has not been well studied. We retrospectively studied 54 patients who underwent repair of an orbital blowout fracture. A minimum of 6 months follow-up was available for all patients included in the study. A total of 47 of 54 (86%) patients had clinically significant diplopia preoperatively, and 20 of 54 (37%) remained diplopic. A total of 17 of 54 (31%) fractures involved the medial wall and orbital floor, and 13 of these 17 patients (86%) had postoperative diplopia. Patients with combined orbital floor and medial wall fractures appear to be at higher risk for clinically significant diplopia postoperatively than those with fractures of the orbital floor only. The explanation for this observation may be related to a greater difficulty in restoring the preoperative contour of orbits with combined fractures.

Amblyopia in congenital ptosis.

This study evaluates the association between congenital ptosis and amblyopia. Amblyopia was detected in 7 of 36 (19%) patients with congenital ptosis. Two patients (6%) with amblyopia had no contributing factors other than the presence of congenital ptosis. A statistically significant correlation between severe nonocclusive ptosis (greater than or equal to 4 mm) and the development of amblyopia was identified. No new cases of amblyopia developed after surgical repair of the ptosis, suggesting early surgery for severe nonocclusive congenital ptosis may decrease the incidence of amblyopia.

Current techniques of enucleation: a survey of 5,439 intraorbital implants and a review of the literature.

Enucleation is a commonly performed procedure. A multitude of intraorbital implants are available for use following enucleation. Each has advantages and disadvantages. This survey report represents the most comprehensive evaluation yet of the current trends in the rehabilitation of the anophthalmic socket. The membership of the American Society of Ophthalmic Plastic and Reconstructive Surgeons (ASOPRS) was surveyed. Information was requested regarding preferred intraorbital implants, complications associated with each implant, and some details of current surgical techniques. Hydroxyapatite (HA) was used in 56% of primary enucleations by this group as compared to 1% in 1989. In comparison to other leading implants, HA was found to have equally low or lower complication rates when poor motility, infection, extrusion, migration, superior sulcus deformity, enophthalmos, lower lid malposition, and contracted fornices were assessed. A detailed discussion of these various complications is presented. The majority (59%) of ophthalmic plastic surgeons use donor sclera when placing an intraorbital implant. HA was clearly the implant material most used by ophthalmic plastic surgeons in 1992, and may be the material of choice for enucleation. To date it has achieved better postoperative results and a favorable side effect profile. Because it has been available for only 5 years, more time is necessary to determine its long-term success rate. Despite theoretical concerns of the transmission of infectious agents with the use of donor sclera, the majority of surgeons use this material when placing an intraorbital implant.

Changes in refraction and keratometry after surgery for acquired ptosis.

A retrospective study involving 47 lids in 26 patients was conducted to determine changes in refraction and keratometry after surgery for acquired ptosis. Refractive and keratometric data were obtained prior to and 6 months after levator surgery. Data were analyzed for changes in refractive sphere, cylinder, and cylindrical axis, as well as keratometry, toricity, and axis of toricity. Although patients noted subjective change in vision postoperatively and demonstrated changes in their refractive error, the changes were statistically insignificant. Consistency was noted; the cylindrical axis and the axis of toricity remained relatively stable after surgery.

Myositis ossificans masquerading as a recurrent spindle cell lipoma of the orbit.

A spindle cell lipoma developed in the right orbit of a 43-year-old woman whose medical history was only significant for chronic asthma. Sixteen months after nearly complete excision of the tumor, the patient presented with eyelid swelling, orbital pain, and a calcified apical mass as demonstrated by computerized tomography (CT). Recurrent tumor or a second neoplasm was suspected. Histologic examination revealed myositis ossificans. To our knowledge, this is the first reported case of myositis ossificans in the orbit.

Clinical bacteriology of dacryocystitis in adults.

To better define the spectrum and relative incidence of pathogens causing dacryocystitis in adults, samples of purulent lacrimal sac contents were obtained from 236 patients undergoing dacryocystorhinostomy for a clinical diagnosis of dacryocystitis. Positive culture results were obtained in 52.5%. Cultures were pure, consisting of a single organism in 71%, and were mixed in 29%. Gram-positive organisms were most common, accounting for 64.5% of the isolates. Staphylococcus epidermidis, comprising 27.3% of the isolates and Staphylococcus aureus, comprising 22.1% of the isolates, were the most frequently encountered organisms. Gram-negative organisms were present in 27.3% of the isolates with Pseudomonas aeruginosa the most common, accounting for 8.7% overall. Anaerobic organisms were found in 7.0% of the isolates with Propionibacterium acnes the most frequent, recovered in 4.7% overall. Unexpected findings included the paucity of Streptococcus pneumoniae organisms recovered and the high incidence of involvement by gram-negative and anaerobic organisms.

Mucoepidermoid carcinoma of the lacrimal gland: 25 cases and a review and update of the literature.

Twenty-five cases of mucoepidermoid carcinoma of the lacrimal gland are compiled, the largest series reported to date. Five of these have not been previously reported. Additional follow-up is presented for seven cases previously reported in the literature, and 13 other cases from the literature are reviewed. This study suggests that histologic grading of the tumor into low- (grades 1 and 2) and high-grade (grade 3) tumors is most predictive of prognosis and can be used to formulate a therapeutic plan. Of the 16 patients with a known histologic grade for their tumors, 8 had low-grade tumors and 7 of these patients survived after extirpation with or without radiotherapy. On the other hand, only 1 of the 8 patients with high-grade tumors for which extended follow-up was available has remained tumor free. The authors suggest that low-grade tumors can be treated with complete extirpation with or without adjuvant radiation and that these tumors generally have a good prognosis. Grade 3 tumors, on the other hand, may be treated aggressively with exenteration and excision of bone, if needed, as well as adjuvant radiation. But these tumors, despite this treatment, carry a poor prognosis.

Malignant peripheral nerve sheath tumor of the orbit in a 15-month-old child. Nine-year survival after local excision.

BACKGROUND: Malignant peripheral nerve sheath tumors are extremely rare orbital tumors that carry a poor prognosis despite wide excision with disfiguring surgery, chemotherapy, or radiotherapy. The authors present the youngest reported case, a 15-month-old boy who underwent an orbitotomy to excise a bilobed tumor from the right orbit. FINDINGS: Histologic examination revealed a malignant peripheral nerve sheath tumor; standard treatment options, including orbital exenteration, chemotherapy, and radiotherapy, were denied and instead the patient was followed with serial computed tomography scans and magnetic resonance imaging. RESULTS: Nine years later, the patient remains without evidence of recurrent tumor and visual acuity is 20/20. CONCLUSION: This patient's course suggests that orbital malignant peripheral nerve sheath tumors, if believed to be completely excised at the time of surgery, might be followed with careful neuroimaging studies for signs of recurrence.

Atypical presentation of fungal dacryocystitis. A report of two cases.

BACKGROUND: Candida albicans has only rarely been implicated in nasolacrimal duct obstruction. Its association with dacryoliths is well known, but it is unclear whether it is an etiologic factor or is present as a result of the obstruction. FINDINGS: The authors report 2 cases of fungal dacryocystitis that were not associated with dacryolith formation and where Candida species appear to be the primary etiologic agent. CONCLUSION: The possibility of a fungal infection should be considered in the evaluation of "routine" chronic dacryocystitis, particularly in the presence of corneal ulceration or postoperative endophthalmitis, as prompt initiation of appropriate therapy may be crucial.

Complications of surgery for orbital tumors.

Orbital tumors represent a small but significant portion of ophthalmologic surgery, and few reports of the associated complications are available. This retrospective review was undertaken to assess the overall complication rate of a large series of orbital tumors, as well as to determine possible risk factors that may guide surgeons in the future. There were 137 orbital tumors managed by a total of 14 surgeons at one hospital during a 7-year period. There was an overall 12.4% complication rate (17/137), affecting only 3 of 97 anterior orbitotomies (3%), but 14 of 40 lateral orbitotomies (35%). The location appeared to be the most significant factor, with the majority of complications associated with intraconal tumors.