Orbital lymphangioma with intracranial extension.

We report a case of biopsy-proven orbital lymphangioma with contiguous spread intracranially in a 14-year-old boy. The patient had a history of congenital orbital lymphangioma and hydrocephalus. Multiple functional and cosmetic periorbital surgeries were done over the years. Severe unresponsive amblyopia developed along with disfiguring anterior orbital and brow invasion of tumor. Since the age of 4 years, the patient had had 12 episodes of periorbital and orbital cellulitis, often after upper respiratory infections. CT and MRI scans have shown progression of the tumor posteriorly beyond the orbital confines. The tumor, now present in the superior and inferior orbital fissure and the paranasal sinuses, extends extradurally into the middle cranial fossa. This case is unique, with documentation of the benign tumor's progressive posterior extension intracranially, along with repeated episodes of severe periorbital cellulitis.

Protecting mental health research subjects without prohibiting progress.

Federal regulations governing the protection of human research subjects fail to specifically address research involving persons with mental illness. In 1990 the New York State Office of Mental Health issued regulations covering such research. The regulations are designed to respect the autonomy of psychiatric patients to make decisions about participation in research while protecting patients whose capacity to consent may be impaired. Patients who lack sufficient capacity may be included in research with the consent of a specified legally authorized surrogate if the facility's institutional review board determines that the research cannot be done without the participation of incapable subjects and it is considered likely to produce knowledge of overriding therapeutic importance for persons with the patients's condition or it has the possibility of directly benefiting the patient. In all cases involving more than minimal risk, the consent of the patient's treatment team must be obtained.

Eyelid disorders: recognizing pathologic changes in the older patient.

The eyelids provide a vital function in protecting and cleansing the eye but are also the source of numerous disorders and complaints in your older patients. Clinically, the most important of these problems are suspicious lid lesions that may harbor malignancy, neurologic disorders, and structural malpositions that cause poor lid function and may damage the globe. Many of these disorders require prompt evaluation and often referral to an ophthalmologist for surgical management. Less serious problems such as blepharitis can often be treated in the primary care office setting.

Mycosis fungoides metastatic to the orbit.

We report a case of mycosis fungoides metastatic to the anterior orbit in an 83-year-old woman. The patient had a history of several years' duration of well-controlled primary mycosis fungoides with localized dermatologic T-cell lymphomas, mainly on the lower extremities. She developed gradual proptosis, hyperophthalmos, and vertical diplopia. Computed tomography demonstrated a solid, extraconal mass in the right lower anterior orbit. Biopsy revealed a gristly, yellowish, infiltrating mass at the level of the inferior orbital septum. Pathologic examination revealed anaplastic T lymphocytes with multiloculated, cerebriform nuclei that matched those of the primary mycosis fungoides skin tumors. Mycosis fungoides rarely spreads to the ocular and periocular structures, and this case was unique in that it presented as a pure orbital lesion with sparing of the overlying lids and adnexal structures.

Catastrophic health insurance and cost containment: restructuring the current health insurance system.

Catastrophic health insurance may be necessary to curb rising health care costs in the United States. A major factor in this rise has been the current structure of the nation's health insurance system, which inadequately protects individuals with expensive illnesses, but encourages over-insurance for less expensive illnesses. This Note examines the current health insurance system, and analyzes its impact on health care costs for individuals and society. It evaluates several proposals to modify the structure of the current health insurance system, and recommends the adoption of a catastrophic health insurance plan based on an economic definition of catastrophe. Such a plan would decrease shallow coverage, and would use coinsurance and deductible rates keyed to the individual's income as means of increasing consumer cost consciousness without making necessary care unreasonably expensive. This Note also recommends that a catastrophic plan only cover treatment that has been determined medically necessary by utilization review, and that this review encourage outpatient rather than costly inpatient treatment.