Ocular adnexal lymphoma of the extraocular muscles: case series from the University of Iowa and review of the literature.

PURPOSE: To review and statistically analyze the data of patients with discrete involvement of the extraocular muscles with ocular adnexal lymphoma from the tumor registry at the University of Iowa and to compile with current cases in the literature. METHODS: The records of patients with biopsy-proven orbital lymphoma at the University of Iowa Hospitals and Clinics Department of Ophthalmology and the Tumor Registry of the University of Iowa were reviewed. A review of the literature and meta-analysis were conducted. RESULTS: Eleven patients were identified with biopsy-proven ocular adnexal lymphoma with discrete involvement of the extraocular muscles at the University of Iowa. Additionally, 46 patients were identified in the literature with clinical and radiographic involvement of the extraocular muscles, 31 (67%) with biopsy-proven involvement. In the combined group of 57 patients, 16 (35%) of 45 patients with histopathologic documentation had lymphomas classified as extranodal marginal zone lymphomas. Twenty-five (67%) of the 37 patients with tumor-staging documentation had no extraorbital involvement. CONCLUSIONS: Ocular adnexal lymphoma with discrete extraocular muscle involvement is rare. Most lymphomas found in this area of the orbit are subtypes of B-cell lymphoma. This disease should be included in the differential diagnosis of enlarged extraocular muscles.

Treatment of lower eyelid rhytids and laxity with ablative fractionated carbon-dioxide laser resurfacing: Case series and review of the literature.

BACKGROUND: An increasing array of minimally invasive treatment modalities have evolved for periorbital rhytids. Nonablative fractional photothermolysis has been demonstrated to be effective for periorbital rhytids. OBJECTIVE: We sought to prospectively evaluate eyelid tightening with an ablative fractional photothermolysis laser. METHODS: We conducted a prospective, single blinded study for lower eyelid laxity in 25 subjects with a series of 2 to 3 treatment sessions. RESULTS: The number of treatment sessions required for significant improvement of eyelid laxity ranged from 2 to 3, with an average of 2.44 sessions. For skin texture, the mean score decreased from 3.6 to a mean of 1.2 at 6 months posttreatment (P < .05) for a 62.6% mean improvement. For skin laxity, the mean score decreased from 3.3 to 1.3 at 6 months posttreatment (P < .05) for a 65.3% mean improvement. For rhytids, the mean score decreased from 3.5 to 1.3 at 6 months posttreatment (P < .05) for a 62.1% mean improvement. For overall cosmetic outcome, mean score decreased from 3.6 to 1.2 at 6 months posttreatment (P < .05) for a 65.7% mean improvement. Patients noted moderate postoperative erythema and edema that resolved by the 1-week posttreatment visit. Patients reported minor crusting and oozing that resolved within 48 to 72 hours. LIMITATIONS: This is a prospective, single blinded study in 25 patients with varying degrees of laxity and photoaging affecting eyelid skin. Additional studies assessing degree of improvement for patients with varying degrees of laxity and photoaging at variable parameters are needed. CONCLUSION: Eyelids can achieve significant improvement in skin texture and laxity with ablative fractional photothermolysis.

Presumed oculoglandular syndrome from Bartonella quintana.

BACKGROUND: To describe a case of clinically diagnosed oculoglandular syndrome in a 17-year-old patient that was presumed to be due to Bartonella quintana, as suggested by a positive serologic titer. METHODS: The patient presented to the Massachusetts Eye and Ear Infirmary emergency room with signs and symptoms suggestive of oculoglandular syndrome. He had a follicular conjunctivitis with a conjunctival granuloma of the right eye and an ipsilateral large, tender submandibular lymph node. He had recently acquired a kitten and a clinical diagnosis of cat-scratch disease was made. A laboratory workup was initiated to determine the cause of this clinical presentation and empirical treatment with antibiotics was started. RESULTS: All laboratory results were negative or normal except for the IgM titer to Bartonella quintana, which was elevated. The patient responded well to treatment and his symptoms resolved within a few weeks. DISCUSSION: Bartonella quintana infection, a pathogen prevalent in HIV-infected, homeless, or alcoholic patients, is a possible etiologic agent of cat-scratch disease and the associated condition of oculoglandular syndrome.

Odontogenic orbital inflammation: clinical and CT findings--initial observations.

PURPOSE: To retrospectively review computed tomographic (CT) and clinical findings in patients with odontogenic orbital infection. MATERIALS AND METHODS: Approval from the institutional review board was obtained for chart and scan review, and informed consent was waived for this HIPAA-compliant study. Five patients, two male and three female (median age, 37 years; age range, 13-55 years), who had odontogenic orbital cellulitis underwent clinical evaluation, CT scanning, and treatment. CT findings, including periapical lucency suggesting abscess, sinus opacification, and the route of spread of infection, were analyzed in each patient. Imaging, clinical, and surgical findings, including the initial clinical diagnosis and the presence of a periapical abscess at surgery and at pathologic examination, were compared. RESULTS: Periapical lucency and sinus opacification were seen in all patients. The route of infection spread was through either the premalar soft tissues or the maxillary sinuses. The odontogenic origin of the orbital infection was not clinically suspected in any patients. Correct diagnosis was later made at CT in all patients. Four patients had periapical abscesses at pathologic analysis, and the fifth patient had apical periodontitis at clinical analysis and granuloma at pathologic analysis. Dental surgery was required in each of the five patients for resolution of infection; four patients underwent extraction of the infected tooth, and one patient underwent incision and drainage of a periapical abscess. CONCLUSION: Abnormal periapical lucency, widening of the periodontal ligament space, and the presence of a subperiosteal abscess suggested an odontogenic origin of orbital infection.

Primary meningococcal conjunctivitis in an adult.

PURPOSE: To describe a case of primary meningococcal conjunctivitis mimicking epidemic keratoconjunctivitis. METHODS: Review of a case history and current literature. RESULTS: A 28-year-old man presented with 5 days of a bilateral follicular conjunctivitis and subepithelial corneal infiltrates. Initial diagnosis of adenoviral conjunctivitis was made. Initial Gram stain of conjunctival exudates was negative. Cultures grew Neisseria meningitidis. Systemic antibiotics were instituted with adjunctive topical therapy. The conjunctivitis resolved with no evidence of systemic invasion. CONCLUSIONS: The clinical picture of Neisseria meningitidis conjunctivitis can overlap with other infectious organisms including adenovirus. Early diagnosis and systemic antibiotic therapy are critical to prevent bacteremic spread of infection.

Two cases of orbital lymphangioma associated with vascular abnormalities of the retina and iris.

PURPOSE: To report 2 patients with combined intraocular and orbital vascular abnormalities. DESIGN: Two interventional case reports. MAIN OUTCOME MEASURES: Clinical and pathologic findings. INTERVENTION/TESTING: Orbitotomy, fluorescein angiography, magnetic resonance imaging, and radiation therapy. RESULTS: Two patients presented with vision loss, intermittent proptosis, and cosmetic deformity. These patients had orbital lymphangioma, ipsilateral retinal and iris vascular malformations, and smaller corneal diameter on the affected side. CONCLUSIONS: The coexistence of these diverse vascular anomalies supports the established hypothesis of pluripotential orbital vascular anlagen. Disruptive influences of various types during embryogenesis or development may produce a variety of congenital orbital and intraocular vascular malformations.

Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri.

PURPOSE: To report the first case of bilateral cavernous sinus thromboses and bilateral intraorbital abscesses secondary to Streptococcus milleri. STUDY DESIGN: Single interventional case report. INTERVENTION AND TESTING: The findings of the ophthalmic evaluation, radiographic imaging, medical and surgical intervention, specimen cultures, and clinical course were analyzed. RESULTS: A 17-year-old female had bilateral proptosis, decreased vision in the left eye, and altered mental status at presentation. An orbital compartment syndrome developed in the left eye and purulent material was present after lateral canthotomy, suggestive of an intraorbital abscess. Magnetic resonance imaging (MRI) scans revealed bilateral cavernous sinus thromboses, and subsequent computed tomographic (CT) scans revealed bilateral intraorbital abscesses in the setting of acute ethmoid and sphenoid sinusitis. Antibiotic treatment and surgical drainage of the orbital abscess and sinuses was performed, and specimen cultures revealed S. milleri. After surgery, the patient experienced hearing loss and a right internal capsule infarct, in addition to complete vision loss in the left eye. A second intraorbital abscess developed in the right eye and was drained surgically. The vision remained 20/20. CONCLUSIONS: Streptococcus milleri is a virulent organism with a propensity to form abscesses in multiple areas of the body and should be considered as a possible etiologic agent in abscess formation of the orbit and cavernous sinus thrombosis.

The evolution of endonasal dacryocystorhinostomy.

Dacryocystorhinostomy is an important treatment in the relief of tearing. Through the years, there have been several advances in this procedure. Once performed only from an external approach, the advent of rigid endoscopes and endoscopic instrumentation has made the endonasal approach a reality. Advantages of the endonasal approach include lack of a cutaneous incision and excellent visualization of intranasal pathology, which is often the cause of dacryocystorhinostomy failure. Preoperative evaluation including a detailed medical history, physical examination with office endoscopy, and imaging, as well as postoperative care are important. Surgical technique with detailed knowledge of intranasal anatomy and meticulous attention to hemostasis are critical. Endonasal laser-assisted dacryocystorhinostomy is also performed today, and special preoperative considerations and key features of the lasers available are important in the selection of a laser for tissue or bone ablation during the procedure. Endoscopic conjunctivodacryocystorhinostomy is performed today, and given the critical nature of proper length and placement of the Jones tube intranasally, provides the significant advantage of intranasal visualization. Endoscopic dacryocystorhinostomy in children is also performed today; however, challenges such as small nasal anatomy and maintenance of the intranasal osteomy postoperatively in a child are significant issues.