Evisceration with scleral modification.

PURPOSE: To describe an evisceration technique that combines scleral modification with optic nerve release for coverage of any sized orbital implant. METHODS: The medical records of 70 patients who underwent the described evisceration procedure were reviewed. RESULTS: The average implant was 20 mm in diameter, with 50 patients (71%) receiving a solid polymethylmethacrylate sphere. Fifty-eight patients (83%) had a history of at least one previous ocular surgery, and 12 patients (17%) had phthisical eyes preoperatively with moderate to severe scleral cicatrization. Postoperatively, there were two cases of new or worsened ptosis, no cases of worsened motility, and no cases of implant extrusion. CONCLUSION: Evisceration with scleral modification is a simple and effective procedure that allows placement of any size orbital implant. Surgical results are excellent with few complications.

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.

Frontal periosteum as an exposed orbital implant cover.

PURPOSE: To describe the surgical technique of harvesting frontal bone periosteum, through an eyelid-crease incision, for coverage of orbital implants. METHODS: A retrospective review of the medical records of 15 patients who underwent the procedure. RESULTS: Eleven patients had surgery to cover exposed orbital implants, whereas in 4 patients the periosteal graft was used as an implant cover during enucleation. Periosteal grafts as large as 25 mm in diameter can be harvested. Recurrent exposure developed in 2 patients who had complicated histories of local trauma. One of these patients required a secondary dermis-fat graft, and the other experienced spontaneous granulation. The remaining 13 patients had excellent results without complications. CONCLUSION: Harvesting frontal bone periosteum, through an eyelid-crease incision, for orbital implant coverage is a relatively straightforward surgical technique. The procedure can be performed in the office under local anesthesia and yields excellent results. Recurrent exposure occurred only in 2 patients with histories of significant local trauma.

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.

Evidence of optic pathway gliomas after previously negative neuroimaging.

PURPOSE: The authors emphasize the potential for the development of anterior visual pathway gliomas, evidenced by computed tomography (CT) or magnetic resonance imaging (MRI) scans, in neurofibromatosis type 1 (NF1) patients who previously had normal neuroimaging studies. METHODS: The clinic charts and CT and MRI scans were retrospectively reviewed for all patients evaluated at the neurofibromatosis clinic of one referral center over a period of 7 years. Patients with neuroimaging studies demonstrating anterior visual pathway gliomas who previously had normal scans were identified, and their cases are described in detail. A similar, previously reported series, from the pediatric literature, was also reviewed. RESULTS: Eight percent (28/360) of patients had CT or MRI scans revealing optic gliomas. Two of these patients had normal neuroimaging studies previously. CONCLUSION: A negative neuroimaging study in an NF1 patient does not exclude the future development of an optic glioma.

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.

Visual outcome in bilateral nonarteritic anterior ischemic optic neuropathy.

BACKGROUND: Nonarteritic anterior ischemic optic neuropathy (NAION) is a common cause of visual loss in the older population. Bilateral NAION is a well-documented entity; however, no study to date has compared the visual outcome between affected eyes. METHODS: The authors retrospectively reviewed the charts of 99 patients with diagnoses of NAION over 3 1/2 years. In the 23 patients with bilateral involvement, 16 were included in the study for analysis of final visual outcome between affected eyes. Snellen acuity, Ishihara color plates, and Humphrey automated perimetry were evaluated as the parameters of visual function. Descriptive analysis of the outcome between affected eyes for each parameter is presented as a frequency distribution of pre-defined groups. Statistical significance is established using nonparametric tests. RESULTS: Bilateral NAION was found in 23% (23/99) of the patients studied. The authors identified a high percent agreement between eyes with regard to visual acuity (81% within 3 Snellen lines), color vision (69% within 3 plates), and Humphrey visual field (75% within 5 decibels of mean deviation). Additionally, there was a statistically significant correlation between affected eyes for all three visual parameters: visual acuity (P = 0.043), color vision (P = 0.001), and Humphrey visual field (P = 0.039). CONCLUSION: The authors found a high percent agreement and statistically significant correlation in final outcome between affected eyes of patients with bilateral NAION for visual acuity, color vision, and visual field loss. With a larger series, it may be possible to predict the visual outcome of the second affected eye based on the parameters of the first eye.

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.

Optic neuropathy, headache, and diplopia with MRI suggestive of cerebral arteritis in relapsing polychondritis.

The pathogenesis of central nervous system disease in relapsing polychondritis (RPC) is unknown but may be related to cerebral arteritis. Previous reports have described clinical and histopathologic evidence of cerebral vasculitis in RPC; however, a neuroimaging correlate has not been reported. We present a 36-year-old man with neuro-ophthalmic features of RPC whose magnetic resonance imaging revealed multifocal gray- and white-matter high intensities. This pattern is consistent with cerebral arteritis as described in other systemic vasculitides.

Pilocarpine-associated allograft rejection in postkeratoplasty patients.

Corneal allograft rejection is a major cause of graft failure. Identifying possible risk factors for rejection may improve chances for successful outcome. We report three cases of graft rejection associated with the use of post-operative pilocarpine at different concentrations. Pilocarpine was used to treat persistent epithelial defects or raised intraocular pressure. The patients were managed until their rejection episodes resolved. In each case, graft rejection ensued in a quiet eye after initiating treatment with pilocarpine, without other change in medications. Each graft rejection episode resolved with discontinuation of pilocarpine and administration of prednisolone acetate. We propose that if pilocarpine does indeed diminish corneal allograft immune privilege and enhance graft rejection, the mechanisms may include induced intraocular inflammation and altering of anterior chamber associated immune deviation. This is the first report implicating a topical ophthalmic medication with possible corneal allograft rejection.

Sebaceous gland hyperplasia of the caruncle.

The caruncle is an ocular adnexal structure composed of both mucosal and epidermal elements. Consequently, a number of benign and malignant lesions of epithelial and supportive tissues may arise in this area. Lesions of the caruncle are rarely reported, and their appropriate diagnosis and management may be uncertain. One such lesion is sebaceous gland hyperplasia. Of all caruncular lesions that undergo excision, sebaceous gland hyperplasia is infrequently encountered. We have observed four cases of sebaceous gland hyperplasia of the caruncle over the last 2 years. Our observations suggest that this lesion has a characteristic onset, progression, and appearance, enabling diagnosis to be made on clinical examination alone. Excision is indicated only if there is an atypical presentation, a carcinoma is suspected, if mass effect causes discomfort or epiphora, or if cosmesis is an issue.

Coralline hydroxyapatite spheres as secondary orbital implants in anophthalmos.

BACKGROUND: Secondary reconstruction of the anophthalmic socket is frequently challenging. A number of surgical techniques are described to improve the cosmetic and functional outcome. Recently, the use of hydroxyapatite as a primary orbital implant after enucleation has gained popularity and yielded encouraging surgical results. There are no published reports concerning the use of hydroxyapatite as a secondary orbital implant in anophthalmos. METHODS: The authors reviewed the charts of 17 patients who received a secondary hydroxyapatite orbital implant to rehabilitate the anophthalmic socket. Each patients' preoperative and postoperative photographs, socket appearance, implant and prosthetic motility, and overall impressions of the surgical outcome were analyzed. Complications of surgery and secondary procedures were reviewed. RESULTS: All except one patient attained an improved prosthetic appearance postoperatively and 76% achieved improved implant and prosthetic motility. Four patients undergoing surgery early in the series had worsening of pre-existing ptosis. In two patients, implant exposure developed; a socket infection with subsequent loss of the implant developed in one of these patients. Eight patients underwent additional eyelid and orbital surgery at the time of secondary implant surgery, whereas nine patients required additional staged procedures. CONCLUSION: Secondary orbital implantation with the coralline hydroxyapatite sphere is an encouraging alternative to traditional secondary orbital implant surgery. Surgical outcomes in this study were excellent with few complications and high patient satisfaction.