Involutional entropion repair with fornix sutures and lateral tarsal strip procedure.

PURPOSE: To evaluate the long-terrm effectiveness of fornix suture placement combined with a lateral tarsal strip procedure in correcting involutional entropion. Published reports regarding various surgical techniques and results are reviewed. METHODS: This retrospective study reviewed 119 patients with involutional lower eyelid entropion who underwent surgical repair between January 1987 and May 1999 at the Bascom Palmer Eye Institute. Exclusion criteria included follow-up duration of less than 6 months, previous lower eyelid blepharoplasty, previous conjunctival surgery other than chalazion removal, or cicatricial entropion. The three surgical subsets were (1) combined lateral tarsal strip and fornix sutures: (2) fornix sutures alone; and (3) lateral tarsal strip procedure alone. The chart review was complemented by a telephone questionnaire to assess the long-term clinical outcome, complications, and patient satisfaction. RESULTS: One hundred fifty-two eyelids in 119 patients were included. One hundred twenty-five eyelids had combined surgery (lateral tarsal strip with fornix sutures), 9 eyelids had only fornix suture repair, and 18 eyelids had repair with only the lateral tarsal strip procedure. The recurrence rate in these three surgical subsets was 1.6%, 33%, and 22%, respectively, with average follow-up of 36 months. One case of incisional cellulitis was encountered. Postoperative ectropion was not seen in the group having the combined lateral tarsal strip and fornix suture procedure. CONCLUSIONS: Suture advancement of the lower eyelid retractors in conjunction with a lateral tarsal strip procedure is a simple, quick, physiologic, and effective approach in achieving long-lasting correction for involutional entropion.

Sebaceous carcinoma of the eyelid treated with Mohs micrographic surgery.

BACKGROUND: Sebaceous carcinoma is an aggressive neoplasm that commonly arises from the meibomian glands of the eyelids and other sebaceous glands of the ocular adnexa. Historic data indicate a nearly 30% local recurrence rate with standard surgical excision. Excision by means of Mohs micrographic surgery may be more efficacious. However, reports documenting the effectiveness of this technique for the treatment of eyelid sebaceous carcinoma have been limited to a few cases. OBJECTIVE: We report our experience in the treatment of ocular sebaceous carcinoma with the Mohs fresh tissue technique. METHODS: Eighteen patients with a diagnosis of sebaceous carcinoma of the eyelid who underwent resection by means of the Mohs fresh tissue technique during the years 1988-1998 were reviewed. RESULTS: Sixteen of the 18 patients were free of disease after an average follow-up of 37 months (11.1% recurrence rate). One patient who experienced local recurrence also had metastatic disease of the parotid lymph nodes (5.6% metastatic rate). The recurrence and metastasis were noted 9 months after excision. The other patient experienced a local recurrence 19 months postoperatively. Both patients exhibited pagetoid spread and involvement of both the upper and lower eyelid at the time of Mohs excision. CONCLUSION: Mohs surgery offers excellent results when used as the primary treatment modality for sebaceous carcinoma of the eyelid. When compared with historic series of standard surgical excision, Mohs micrographic surgery has a significantly lower recurrence rate and metastatic rate.

Lacrimal gland ductal cyst abscess.

PURPOSE: To describe a case of lacrimal gland ductal cyst complicated by secondary infection. METHODS: Case report. RESULTS: A 51-year-old woman presented acutely with an enlarging, painful mass in the superotemporal fornix. Clinical examination, echography, and surgical evaluation revealed a lacrimal gland ductal cyst with abscess formation. The lacrimal gland cyst was treated with oral antibiotics in combination with incision, drainage, and marsupialization. CONCLUSIONS: Lacrimal gland ductal cysts are rare but must be considered in the differential diagnosis of lacrimal gland and upper eyelid mass lesions. Typically, lacrimal gland ductal cysts develop after chronic inflammation, infection, or trauma. We describe a patient who presented acutely with a lacrimal gland ductal cyst associated with a rare complication of abscess formation.

Congenital orbital cyst detected and monitored by prenatal ultrasonography.

PURPOSE: High-resolution prenatal ultrasound can allow for early detection and monitoring of many fetal anomalies, including those involving the globe and orbit. We describe a case of a congenital orbital cyst detected and monitored by prenatal transvaginal ultrasonography. METHODS: After detection of a congenital orbital cyst, serial transvaginal ultrasound examinations were performed through the remainder of the pregnancy to monitor the growth and development of the fetus and the orbital cyst. RESULTS: A large retrobulbar orbital cyst causing extreme proptosis was detected at 23 weeks of gestation and monitored through the remainder of the pregnancy. Lack of growth, benign behavior, and appropriate interval fetal growth without destruction of adjacent structures was noted. After birth, early surgical intervention allowed for complete surgical excision of the cyst without the need for enucleation or exenteration. Fifteen months after excision, the patient wore a scleral shell and had a good cosmetic appearance with good ocular motility. CONCLUSIONS: Prenatal ultrasound may allow for early detection of orbital masses. To our knowledge, this report describes the first case of a congenital orbital cyst detected and monitored by prenatal ultrasonography.

Sebaceous cell carcinoma of the eyelid and the human immunodeficiency virus.

PURPOSE: Patients infected with the human immunodeficiency virus (HIV) are at increased risk for developing malignancies, which are acquired at a younger age and are more aggressive. Sebaceous cell carcinoma is a rare eyelid tumor typically occurring in the seventh decade of life. We report two cases of sebaceous cell carcinoma in young HIV-infected patients. METHODS: Case series and review of the literature. We describe two HIV-infected patients with sebaceous cell carcinoma of the eyelid and caruncle. The first patient was a 36-year-old woman with a 9-month history of an enlarging right lower eyelid mass. The second patient was a 34-year-old man with a 6-month history of an enlarging right caruncular mass. RESULTS: Biopsy showed both masses to be sebaceous cell carcinoma. The first patient underwent Mohs' micrographic excision of the lesion followed by reconstruction of the full-thickness eyelid defect with a combination of tarsoconjunctival and myocutaneous advancement flaps. The second patient underwent exenteration because of orbital involvement. CONCLUSION: Sebaceous cell carcinoma should be considered for any suspicious eyelid lesion in young HIV-infected patients.

Radiation therapy for local control of eyelid sebaceous cell carcinoma: report of two cases and review of the literature.

PURPOSE: Because of previous reports of increased rate of recurrence and mortality after radiation therapy, eyelid sebaceous cell carcinoma has been considered radioresistant. Recent reports of success with primary radiation therapy have been attributed to advancements in irradiating technology and technique. Two cases of eyelid sebaceous cell carcinoma successfully treated with radiation therapy are reported. The techniques used are compared with the techniques described in previous reports, and factors favoring successful treatment are reevaluated. METHODS: Case series and review of the literature. Two cases of eyelid sebaceous cell carcinoma that underwent radiation therapy are described. Both patients were offered, but refused, surgical excision. One patient received 69 Gy combined superficial and megavoltage x-ray irradiation to the left lower eyelid. The second patient received 59 Gy megavoltage electron beam irradiation to the right upper eyelid. A review of the literature was performed, and Fisher's exact test analysis was used to compare the results of all reported cases treated with < or =55 Gy with those treated with >55 Gy. RESULTS: In both cases, the tumor responded to radiation therapy. One patient died 39 months after treatment, of myocardial infarction. The second patient is without clinical evidence of tumor recurrence 46 months after treatment. Fisher's exact test showed an advantage to patients treated with >55 Gy radiation (p = 0.05). CONCLUSION: Radiation therapy with an appropriate delivery system is effective as a curative treatment for eyelid sebaceous cell carcinoma when >55 Gy of radiation dose is delivered. It should be considered for patients seeking an alternative to surgical excision.

Central corneal dellen: a complication of upper eyelid tarsotomy.

PURPOSE: To report a rare complication of central corneal dellen that developed after a tarsotomy procedure to correct cicatricial entropion. METHOD: Central corneal dellen developed in a 60-year-old woman 3 months after a tarsotomy procedure for correction of cicatricial upper eyelid entropion. Eversion of the upper eyelid showed a retracted and buckled tarsal plate and the presence of a 5 x 10-mm depression between the edge of the tarsoconjunctival flap and lower tarsal bridge. RESULTS: The recalcitrant corneal defect was reversed when the upper eyelid tarsoconjunctival surface contour was restored by full-thickness tarsal incisions designed to flatten the dome-shaped tarsal plate. CONCLUSION: An upper eyelid defect producing suboptimal lid-globe apposition during lid closure can lead to dellen formation because of focal corneal dehydration as the result of an altered tear meniscus.

A simple maneuver to reposit a subluxed globe.

In patients with thyroid orbitopathy, severe lid retraction and proptosis may produce spontaneous axial globe subluxation. This acute event is characterized by anterior displacement of the globe beyond the orbital rim, retraction of both upper and lower eyelids behind the globe, and tethering of the optic nerve. This frightening occurrence causes severe pain because of exposure keratopathy and forward displacement of the globe, as the retracted eyelids are squeezing the retrobulbar tissues. Spontaneous globe subluxation frequently occurs at home or at work, and patients experiencing this for the first time often panic because they have never been forewarned of this possibility nor received any instruction on how to attend to such an emergency. The lack of concise patient instruction for a quick and safe method of self-administered globe reposition is the main impetus for the design of current technique.

Diagnosis and management of allergic fungal sinusitis with orbital involvement.

PURPOSE: Allergic fungal sinusitis (AFS) is a noninvasive disease characterized by recurrent sinusitis. This condition is commonly treated with surgical debridement and several months of systemic corticosteroids. The treatment of AFS is examined in this study. METHODS: A retrospective case series of three patients with AFS. RESULTS: All three patients were treated with surgical debridement and less than one month of systemic corticosteroids. The patients then were treated with intranasal corticosteroids and monitored closely. Antifungal therapy was not used. All three patients remained disease-free during follow-up ranging from 12 months to 36 months. CONCLUSIONS: Surgical debridement and systemic corticosteroids for less than four weeks followed by intranasal corticosteroids may provide long-term control of AFS. Additional study is recommended to examine further the optimal treatment for AFS.

Nasolacrimal duct obstruction and orbital cellulitis associated with chronic intranasal cocaine abuse.

OBJECTIVE: To report the association of acquired nasolacrimal duct obstruction and orbital cellulitis in patients with a history of chronic intranasal cocaine abuse. METHODS: Retrospective, consecutive case series. Results of imaging, histopathologic examinations, and clinical courses of these patients were studied. RESULTS: Five women and 2 men (mean age, 41 years) with a history of chronic intranasal cocaine abuse (mean, 11 years; range, 5-20 years) presented with epiphora and in some cases acute onset of periorbital pain, edema, and erythema associated with fever. The suspicion of intranasal cocaine abuse was made on anterior rhinoscopy with the detection of an absent nasal septum and inferior turbinate. Computed tomographic and magnetic resonance imaging findings in 4 patients included extensive bony destruction of the normal orbital wall architecture, opacification of the sinuses, and the presence of an intraorbital tissue mass. Histopathologic examination of the nasolacrimal duct in 2 patients and of the orbital mass in a third patient revealed marked chronic inflammation with fibrosis causing secondary nasolacrimal duct obstruction. Six patients were treated with systemic antibiotics followed by dacryocystorhinostomy in 3 patients, and a pericranial flap to insulate the exposed orbit in 1 patient. CONCLUSIONS: Chronic intranasal cocaine abuse can result in extensive bony destruction of the orbital walls with associated orbital cellulitis, and should be included in the differential diagnosis of acquired nasolacrimal duct obstruction. Anterior rhinoscopy is very helpful in establishing the correct diagnosis in these patients.

Necrotizing fasciitis after cosmetic blepharoplasty.

PURPOSE: To report a case of necrotizing fasciitis after cosmetic blepharoplasty. METHOD: Case report. A 74-year-old woman with history of type II diabetes mellitus underwent bilateral upper eyelid blepharoplasty. Postoperatively she developed fever, grayish discoloration of the skin, violaceous bullae, and a right facial nerve palsy. Necrotizing fasciitis was diagnosed and treated with intravenous antibiotics, debridement of necrotic tissue, and hyperbaric oxygen therapy. RESULTS: The infection resolved, but the patient required reconstruction for correction of cicatricial ectropion. CONCLUSION: Necrotizing fasciitis is a potentially fatal infection that typically occurs in the setting of trauma. Early recognition of its pathognomonic signs and aggressive management are paramount.

Ocular-adnexal lymphoid tumors: a clinicopathologic and molecular genetic study of 77 patients.

PURPOSE: To determine whether molecular genetic analysis of ocular-adnexal lymphoid tumors, combined with histopathology and tumor location, is helpful in predicting which patients will develop systemic lymphoma. METHODS: A combined retrospective and prospective study of 77 patients with ocular-adnexal lymphoid tumors was performed. The tumors were subdivided into conjunctival, orbital, and eyelid lesions, and all were studied using both routine histopathology and molecular genetic analysis. RESULTS: Most lesions (70%) were small cell lymphomas of the mucosa-associated lymphoid tissue type, and the majority of tumors (90%) contained monoclonal or oligoclonal populations of lymphocytes discovered on molecular genetic analysis. Additionally, 72% of tumors exhibiting clonality had more than one gene rearrangement. Fifty-three percent of patients developed extraocular lymphoma sometime during the course of their disease. Patients with gene rearrangements on Southern blot hybridization had a 52% incidence of nonocular disease, compared with 63% of those without rearrangements. Patients with conjunctival tumors had a 37.5% incidence of nonocular disease, those with orbital tumors had a 54% incidence, and those with eyelid tumors had a 100% incidence of nonocular lymphoma. Only two patients died as result of systemic lymphoma. CONCLUSIONS: Most ocular-adnexal lymphoid tumors are lymphomas of the mucosa-associated lymphoid tissue type. The majority of tumors exhibit gene rearrangements on molecular genetic analysis, and this technique was not helpful in predicting which patients would develop nonocular lymphoma. Tumor location did have predictive value: Conjunctival lesions had the lowest incidence of nonocular lymphoma, and lid lesions had the highest incidence. Even with disseminated disease, most patients have a favorable prognosis with treatment.

Sino-orbital aspergillosis in acquired immunodeficiency syndrome.

OBJECTIVE: To describe the clinical features, causes, imaging characteristics, treatment, and outcome of patients with the acquired immunodeficiency syndrome (AIDS) and sino-orbital aspergillosis. DESIGN: Records of 5 patients were reviewed. Results of imaging and histopathologic examinations and clinical courses of the patients were studied. RESULTS: There were 3 women and 2 men (mean age, 34.0 years). All had received a diagnosis of AIDS, and mean CD4+ cell count was 0.014 x 10(9)/L (14 cells/mm3). Computed tomographic scanning exhibited heterogeneous, enhancing sino-orbital soft tissue lesions with bony erosion, and magnetic resonance imaging disclosed soft tissue masses hypointense on T1- and T2-weighted images. The infection involved 1 or more paranasal sinuses, with extension into the right orbit in 3 patients and into the left orbit in 2. Patients were treated with aggressive surgical debridement and intravenous antifungal agents. In addition, local irrigation of amphotericin B was performed in 3 patients. Aspergillus fumigatus was found to be the cause in all 5 patients. Intracranial extension developed in 4 patients, and all subsequently died. The 2 longest surviving patients were the only ones being treated with protease inhibitors. Three patients had a history of frequent marijuana smoking. CONCLUSIONS: Sino-orbital aspergillosis is a progressive, relentless, and usually fatal opportunistic infection of advanced AIDS. Patients are first seen with long-standing headache and proptosis with minimal external inflammatory signs. Marijuana smoking may increase the risk for development of sino-orbital aspergillosis in these patients. Aggressive surgical and medical treatment, combined with newer combination therapies using protease inhibitors, may improve the longevity of these patients.

Periocular atypical mycobacterial infections.

OBJECTIVE: To examine the clinical characteristics and management of periocular infections caused by atypical mycobacteria. DESIGN: Retrospective, noncomparative case series. PARTICIPANTS: Six patients were identified with periocular atypical mycobacterial infections: four with Mycobacterium chelonae and two with Mycobacterium fortuitum. INTERVENTION: The treatment of these infections included removal of the foreign bodies with debridement of the lesions. Specimens were sent for histopathologic examination, routine cultures, and fresh tissue for culture after homogenization. MAIN OUTCOME MEASURES: A retrospective review of culture-proven atypical mycobacterial infections involving the periocular tissues was performed. Charts were reviewed for age, gender, infectious organism, medical history, surgical history, presenting symptoms, clinical features, and treatment. RESULTS: Four associations with infection were identified in these patients: immunosuppression, nasolacrimal duct obstruction, the presence of a foreign body, and a history of recent surgery. All six of the patients had at least one of these associations and five of the patients had at least two. Clinical characteristics that may distinguish atypical mycobacterial infections from acute bacterial infections include subacute presentation, firm nodular lesions, mild erythema, mild tenderness, and minimal purulent discharge. All patients had resolution of their infections after debridement and several weeks of systemic antibiotic therapy guided by susceptibility testing. CONCLUSIONS: Periocular atypical mycobacterial infections are uncommon. The clinical history and examination can raise the suspicion of this infection by revealing the clinical characteristics of these infections. Treatment includes removal of foreign bodies, debridement, and long-term systemic antibiotic therapy.

Neoadjuvant intracarotid chemotherapy for treatment of advanced adenocystic carcinoma of the lacrimal gland.

OBJECTIVE: To investigate a new chemotherapeutic regimen as an adjunct to the conventional surgical management of patients with advanced adenocystic carcinoma of the lacrimal gland. PATIENTS AND METHODS: Two patients with extensive adenocystic carcinoma of the lacrimal gland were treated with intracarotid cisplatin and intravenous doxorubicin hydrochloride prior to orbital exenteration. Postoperatively, the patients received 55 to 60 Gy of orbital irradiation, augmented by additional intravenous cisplatin and doxorubicin. Serial clinical and computed tomographic scan examinations were performed to monitor for evidence of recurrent disease. RESULTS: Tumor shrinkage was documented radiographically following this preoperative chemotherapy regimen, downstaging the disease in one case from intracranial involvement to a more surgically amenable intraorbital process. Tumor necrosis was confirmed in the exenteration specimen. Limited morbidity was experienced and both patients have achieved long-term survival to date of 9 1/2 years (114 months) and 7 1/2 years (94 months). CONCLUSIONS: To our knowledge, this is the first report of the efficacy of neoadjuvant intracarotid chemotherapy in the treatment of an advanced adenocystic carcinoma of the lacrimal gland. The combination of cisplatin and doxorubicin and the methods of drug delivery may be factors contributory to the favorable response. The results of this new treatment regimen are encouraging and justify further investigation.

Use of galeal or pericranial flaps for reconstruction or orbital and eyelid defects.

The use of galeal or pericranial flaps for craniofacial reconstruction is well recognized. The excellent blood supply of the flap permits vascularized support for skin, bone, or cartilage grafts in otherwise unsatisfactory recipient sites. The pericranial flap was used in 1 patient with a large orbital bony defect and the galeopericranial flap was used in 3 patients with various periocular defects produced by trauma or following tumor extirpation. In the case of an orbital defect induced by chronic cocaine abuse, the pericranial flap successfully sequestered the orbit from the nasal cavity while providing support for the globe. In 3 of the 4 cases involving eyelid reconstruction, the galeopericranial flap served a dual function in providing vascular supply to the underlying free tarsal graft and to the overlying free skin graft. This tissue flap is analogous to a median forehead flap, except skin is not transposed and a second-stage inset revision is not required.

Microscopically controlled excision of conjunctival squamous cell carcinoma.

Although surgical excision, with or without adjunctive cryotherapy, is an accepted method of managing conjunctival squamous cell carcinoma, histologically verified tumor-free surgical margins cannot be assured by excision alone. We used a tissue conservation method, an adaptation of the Mohs' micrographic technique for cutaneous tumors, to monitor the conjunctival tissue margins by histologic review at initial tumor excision. We treated 19 patients with squamous cell carcinoma of the conjunctiva by this technique. Lamellar sclerectomy was used if the deep tissue margin was positive for residual tumor cell after the first stage review. Adjunctive cryotherapy was utilized in one patient because the deep scleral margin remained positive after lamellar sclerectomy, and further excision was not possible. In all patients, the tumor-free conjunctival defect was allowed to heal by secondary intention. During six months to 60 months of follow-up, no recurrences were documented. The only complication encountered was conjunctival scarring with secondary restricted motility in one patient. We believe this method of tissue margin surveillance offers a high cure rate for the treatment of conjunctival squamous cell carcinoma.