Orbital melanoma presenting as orbital cellulitis: a clinicopathologic report.

Most choroidal melanomas are diagnosed when the tumor is still relatively small and confined to the globe. Rarely, these tumors can escape detection and extend through the sclera. They can reach a large size and create significant orbital inflammation. The authors describe a 71-year-old man with orbital cellulitis secondary to a necrotic choroidal melanoma that invaded the orbit. This tumor had minimal intraocular involvement with a large extrascleral component. On histopathologic analysis, the lesion was best classified as a spindle B melanoma with epithelioid areas (mixed melanoma). The patient was treated with an enucleation and postoperative radiation. This report demonstrates that malignancies in the orbit can present as acute infections. Early suspicion, diagnosis, and treatment of these lesions offer the best chance for survival.

Laser Doppler perfusion imaging of eyelid skin.

We report an initial laser Doppler perfusion study of the eyelids and compare the results with those of other cutaneous regions. Eleven healthy subjects with no prior medical or surgical history, or eyelid malposition underwent laser Doppler perfusion scanning of six skin locations: right forearm, right middle fingertip, right upper eyelid, right lower eyelid, left upper eyelid, and left lower eyelid. Cutaneous perfusion in the four eyelid locations and right middle fingertip were statistically similar to each other but significantly higher than that in the right forearm (p = 0.002). Also, mean perfusion in pretarsal skin was > 50% than that in preseptal skin (p = 0.002). In addition, in an eyelid with histopathologically documented basal cell carcinoma, cutaneous perfusion was significantly higher than the mean of the normal eyelids (p = 0.002). Eyelids are perfused at the same high rate as are other regions of the head, and significantly higher than low flow regions, such as the extremities. Future application of this laser Doppler perfusion scanning include assessing burn depth, postoperative monitoring of periorbital tissue transfer, distinguishing benign and malignant adnexal skin lesions, and establishing the pathologic margins of lid tumors.

Hard-palate mucosa graft in Stevens-Johnson syndrome.

PURPOSE: We evaluated the use of hard-palate mucosa grafts in the treatment of cicatricial entropion and trichiasis associated with Stevens-Johnson syndrome. METHODS: Six patients, two men and four women, were treated with hard-palate mucosa grafts of one or more eyelids with cicatricial entropion, trichiasis, and corneal disease. The follow-up ranged from 19 to 33 months. RESULTS: Visual acuity improved in one of nine eyes and remained stable in the rest. Corneal epithelial disease improved in eight of nine eyes, while in one eye the epithelial defect stabilized. The corneal epithelium of all three corneal transplants remained intact, although one of these patients underwent another corneal transplantation and the other two transplants opacified from rejection. Cicatricial entropion resolved and symblephara improved in all 16 eyelids. Trichiasis resolved or improved in 12 of 16 eyelids and remained stable in the other eyelids. CONCLUSIONS: The chronic relapsing nature of Stevens-Johnson syndrome requires caution in interpreting surgical intervention in the treatment of dysfunctional eyelids. However, hard-palate grafts may be considered for patients with the Stevens-Johnson syndrome and severe ocular surface disease.

Canaliculitis caused by Mycobacterium chelonae after lacrimal intubation with silicone tubes.

Two and a half weeks after a 62-year-old man underwent bilateral nasolacrimal intubation with silicone tubes, canaliculitis and conjunctivitis developed. Cultures yielded Mycobacterium chelonae sensitive to amikacin. Successful therapy required removal of the tubes followed by intensive intravenous and topical chemotherapy. This is, to our knowledge, the first report of mycobacterial infection as a complication of lacrimal intubation.

Eyelid pigment implantation: early and late histopathology.

Full-thickness sections of upper and lower eyelids were obtained from patients who had eyelid pigment implantation performed by one surgeon. These four patients represented eyelid pigment implantation at varying postoperative stages ranging from 6 months to 4 years. Light microscopic evaluation revealed pigment within dermis and superficial orbicularis muscle. Light and electron microscopic evaluation revealed the vast majority of the pigment to be located intracellularly, primarily within macrophages. No foreign-body reaction was seen around the implanted material. Electron probe analysis of the pigment showed only the presence of iron. Analysis of the unused pigment revealed small amounts of silica and magnesium. These substances could not be identified by electron probe analysis in the eyelid tissues.

Preventing conjunctival prolapse and tarsal eversion following large excisions of levator muscle and aponeurosis for correction of congenital ptosis.

Mattress sutures placed from the superior fornix conjunctiva through levator muscle and aponeurosis can be used to reconstruct the superior fornix following extensive dissection and resection of levator muscle and aponeurosis for severe congenital ptosis. This placement of sutures differs from the full-thickness mattress sutures from conjunctiva through skin commonly recommended by many textbooks in oculoplastic surgery, and appears to be more successful in preventing some of the complications that follow this type of oculoplastic surgery.

The lid crease approach to the superomedial orbit.

The lid crease incision of the upper lid allows direct exposure of the orbital septum and levator aponeurosis and can be used to dissect dermoid tumors or any tumor of the middle orbit space from the medial horn of the levator aponeurosis and the tendon of the superior oblique muscle. One advantage of the lid crease incision is its location in the normal eyelid crease, which provides a "front door" approach familiar to the ophthalmic surgeon. Also, the distensibility of the eyelid skin allows for marked retraction of tissues and exposure of large orbital masses well beyond the medial extent of the incision. In addition, the lid crease incision offers significant advantages in completing the dissection of the poorly-defined plane between dermoid tumors and the medial horn of the levator aponeurosis. Finally, with this approach, if there is direct damage to the lid structures, primary repair can be easily accomplished.

Auditory brain-stem responses in Marcus Gunn ptosis.

The auditory brain-stem response (ABR) can detect anomalies both in the auditory pathways and in structures adjacent to these pathways. Patients with Duane's retraction syndrome, associated with hypoplasia of the abducens nerve in the brain-stem, and patients with hemifacial spasm, due to compression of the facial nerve in the brain-stem, have been found to have abnormal ABRs. Marcus Gunn ptosis with 'jaw winking' is considered to be due to misconnection of oculomotor, trigeminal and other cranial nerves. Suspecting that perhaps some 'jaw-winking' phenomena may be due to detectable brain-stem anomalies we tested 7 patients with Marcus Gunn ptosis. Three of the patients demonstrated abnormal ABRs indicative of pontine pathology.

Surgical treatment of the denervated or sagging lower lid.

Paralytic ectropion of the lower eyelid and increased curvature of the lower eyelid associated with anophthalmos both cn be optimally treated by use of an autogenous fascia lata sling. Some patients also have problems with prosthesis retention due to lower eyelid deformity with a shortened inferior fornix. In some instances, it is also necessary to perform a horizontal shortening operation on the lower eyelid. In anophthalmic patients, the relationship between prosthesis size and weight and a sagging lower lid is discussed. In some patients when the lower eyelid is elevated, the patient then has an upper lid ptosis for which it is necessary to perform an appropriate levator shortening operation. Surgical technique and illustrative pre- and post-operative photographs are shown.