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.

A new modification of the standard lacrimal groove director for nasolacrimal intubation.

We devised a new lacrimal groove director, designed for the atraumatic and easy retrieval of the Crawford metal probe. This instrument alleviates many of the problems encountered with the use of the Crawford hook.

Surgical treatment of chemotic conjunctival prolapse following vitreoretinal surgery.

The development of marked conjunctival chemosis following vitreoretinal surgery may be due to extensive intraoperative cryopexy, prolonged surgical time, removal of edematous corneal epithelium, and postoperative face-down posturing for an intraocular gas bubble. The fine suspensory attachments of the conjunctival fornix may be disrupted by the hydraulic dissection of marked chemosis, leading to prolapse of the conjunctiva through the eyelids. This problem can be successfully managed by a combination of conjunctival fornix sutures to invaginate the prolapsed conjunctiva and temporary suture tarsorrhaphy.

A simple and reliable technique for permanent lateral tarsorrhaphy.

A simple and reliable technique for permanent tarsorrhaphy is described that has many advantages over previously reported techniques. it produces a stable and permanent lid adhesion without the use of nonabsorbable sutures or bolsters that require removal, and it can be opened at any time without lash loss, trichiasis, epidermalization of the lid margin, or scarring of the anterior lamella.

Surgical correction of lower-eyelid tarsal ectropion by reinsertion of the retractors.

Lower-eyelid tarsal ectropion is an unusual form of eyelid malposition in which the entire lid is everted. The cause is most likely the disinsertion of the lower-eyelid retractors. In 12 eyelids of six patients, a transconjunctival approach was used to reunite the retractors with the inferior tarsal border. In eight eyelids, a horizontal tightening procedure was also needed. The looping passage of fornix sutures through the full thickness of the eyelid created a vector force that helped rotate the lid margin inward. The subsequent formation of an inflammatory cicatrix induced by the absorbable sutures also contributed to maintain the lid in an upright posture. During follow-up periods ranging from 8 to 36 months, there were no instances of overinversion, recurrent ectropion, or suture abscess.

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.

Clinicopathologic correlate of a fresh eyelid pigment implantation.

An eyelid with freshly applied black eyeliner pigment was examined histologically. X-ray microanalysis of the pigment suspension from the manufacturer's vial indicated that its composition was 98% iron and 2% titanium. Transmission electron microscopic examination disclosed that particles were in the extracellular matrix; intracellular particles were not seen. By light microscopy, implant material was detected in various levels of the dermis and was found in dermal lymphatics as well as within and surrounding a hair follicle. Our study suggests that systemic exposure to the implant material is possible and offers explanations for permanent eyelash loss, which we have seen following this procedure.

Aponeurosis disinsertion in congenital entropion.

Lower lid retractor aponeurosis disinsertion is a well-recognized etiologic factor in many involutional entropion cases, but to our knowledge it has not previously been reported as a cause of congenital entropion. Four congenitally entropic lower eyelids in three patients with no history of birth trauma were all found to have retractor disinsertion during exploratory procedures. All four eyelids were surgically corrected by reinserting the retractors to the inferior tarsal margin. Detailed histologic studies of orbicularis oculi muscle fibers in two cases showed no evidence of fiber hypertrophy. This finding refutes the commonly accepted concept of orbicularis muscle hypertrophy as an etiologic mechanism of congenital entropion.

Mucous membrane grafting for severe palpebral vernal conjunctivitis.

Vernal conjunctivitis usually can be managed medically. In the rare cases that do not respond to medical treatment, surgical intervention has been considered. Four cases of vernal conjunctivitis and one case of probable contact lens-induced giant papillary conjunctivitis were treated with palpebral conjunctival excision and application of a mucous membrane graft. All patients improved symptomatically, with follow-up ranging from 1 1/2 to 14 years. The only complication encountered was recurrence of giant papillae at the conjunctiva-mucous membrane graft junction. Conjunctival excision and mucous membrane grafting is a useful procedure in rare cases of particularly severe vernal conjunctivitis.

Cyanoacrylate adhesive used to stop CSF leaks during orbital surgery.

Butyl-2-cyanoacrylate (Histoacryl Blue) tissue adhesive successfully sealed three cases of CSF leaks encountered during orbital surgery. The application of tissue adhesive was followed by prompt cessation of leak. We have found this tissue adhesive to be a valuable technical adjunct in the intraoperative management of this difficult problem and have not seen any general or local toxic reaction to the material.

Hematoporphyrin derivative photoradiation therapy in managing nevoid basal-cell carcinoma syndrome. A preliminary report.

Hematoporphyrin derivative (HpD) is a photodynamically active dye that is preferentially retained by malignant tissues and initiates a cytotoxic reaction when exposed to red light. Normal tissues adjacent to a tumor retain HpD to a lesser degree and are thus spared damage from the light-induced reaction. We describe the treatment of 40 basal-cell carcinomas in three patients with nevoid basal-cell carcinoma syndrome. All treated lesions showed disappearance of clinically apparent tumor within four to six weeks, and there was no damage to surrounding skin. Thirty-three lesions (82.5%) showed complete response on biopsy findings, while seven showed residual tumor cells. The recurrence rate was 10.8%, with the follow-up ranging from 12 to 14 months. Tumor response was related to the total light dose delivered and the size and location of the tumor.

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.

Results of optic nerve sheath fenestration for pseudotumor cerebri. The lateral orbitotomy approach.

Twenty-eight patients with pseudotumor cerebri underwent 40 optic nerve sheath fenestrations for relief of visual loss or to preserve vision. Twenty women and eight men underwent 16 unilateral fenestrations and 12 bilateral operations. Papilledema disappeared or was strikingly reduced in 24 of 28 patients. The other four patients had gliotic discs (two patients) or were followed up for only a short time. Visual acuity improved in 12 of 40 eyes and remained the same in 22 of 40 eyes. Seventeen eyes had preoperative visual acuity of 20/30 or better. In six eyes visual acuity decreased. Of eight eyes operated on that had visual acuity of 20/200 or worse, only three showed improvement. Visual fields improved in 21 of 40 eyes and remained the same in ten eyes. Five of the ten eyes that did not change had poor vision before surgery. Eight eyes in five patients continued to lose acuity postoperatively. Each of these eight eyes had a concomitant loss of visual field. An additional two eyes developed visual field loss with preserved visual acuity. The indications for surgery are early evidence of progressive loss of visual field or acuity in a patient with pseudotumor cerebri. Severe vision loss presents little opportunity for improvement but fenestration may be used in a last effort to preserve or restore vision.

Tarsal rotational flap for upper eyelid reconstruction.

Reconstruction of full-thickness defects in the upper eyelid presents a special challenge to the oculoplastic surgeon. We present and discuss a new, surgically simple technique for posterior lamella reconstruction of the upper eyelid, which can also be used with other procedures. The surgical technique calls for a vertical strip of tarsus (tarsal flap) to be rotated horizontally and sutured to canthal tendon remnants or periosteum at the orbital rim. This procedure has produced satisfactory to excellent results in our test group, and presents the reconstructive surgeon with several advantages over other techniques.

Neuroimaging of the optic nerve after fenestration for management of pseudotumor cerebri.

The mechanisms by which optic nerve-sheath fenestration is effective remain speculative. Possibilities include surgical production of a cerebrospinal fluid filtration outlet or scarring in the subarachnoid space around the nerve in the vicinity of the fenestration site, with shifting of the pressure gradient from the nerve head to the retrobulbar portion. Two patients who underwent successful optic nerve-sheath fenestration developed a cystlike structure contiguous to the fenestration site, apparently in direct communication with the optic nerve sheaths. This was shown on magnetic resonance imaging (one patient) and orbital echography (both patients). These previously unreported observations may support the hypothesis that fenestration works by creating a filtration apparatus that controls the intravaginal pressure in the subarachnoid space surrounding the orbital segment of the optic nerve.

Optic nerve sheath fenestration in pseudotumor cerebri. A lateral orbitotomy approach.

In patients with pseudotumor cerebri accompanied by loss of vision, optic nerve sheath fenestration is an effective route to prompt recovery of vision. A lateral orbitotomy approach to decompression of the optic nerve is appropriate for the ophthalmologist with adequate orbital experience. A rectangular window of dura and arachnoid, measuring approximately 3 X 5 mm, is excised from the bulbous portion of the optic nerve. It is important that the arachnoid within the window is excised because an intact arachnoid is an effective barrier to cerebrospinal fluid egress. The use of operating microscope, microsurgical instrument, and microdissecting techniques are emphasized. Twenty-eight patients (40 eyes) with progressive visual loss were treated by surgical nerve sheath fenestration. A study of the indications, results, and complications of this procedure is presented in a companion article.

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.

Hematoporphyrin photoradiation therapy for iris neovascularization. A preliminary report.

Photoradiation therapy is a new technique currently under clinical investigation for the treatment of a variety of solid malignant tumors. The technique involves intravenous (IV) administration of hematoporphyrin derivative, a photosensitizing compound that is preferentially retained by malignant cells, and photoactivation of a neoplasm with red light (630 nm) to obtain selective destruction of cancer cells. A modification of this technique was used to treat iris neovascularization produced in a primate model of retinal vein occlusion. Following IV injection of hematoporphyrin derivative, the anterior surface of the iris was exposed to red light for 30 to 45 minutes. In the four eyes treated, there was a marked reduction of fluorescein leakage from the neovascular tissue within 24 hours following treatment. Histologic examination of two eyes demonstrated a selective response of the iris neovascularization to this therapy, with apparent preservation of surrounding tissue.

Neovascular glaucoma after photoradiation therapy for uveal melanoma.

We describe two patients (two eyes) with neovascular glaucoma following photoradiation therapy (PRT) for ciliary body and iris melanoma. Histopathologic examination in one eye eight months after treatment disclosed widespread tumor necrosis. The second patient with iris melanoma showed total clinical disappearance of the lesion and regression of iris neovascularization six months later. The cause of the neovascular glaucoma is uncertain. The marked tumor necrosis induced by PRT might have resulted in release of a vasoproliferative factor that, in turn, led to the development of rubeosis and neovascular glaucoma.

Hematoporphyrin photoradiation therapy for intraocular and orbital malignant melanoma.

Photoradiation therapy (PRT) is a new technique that is currently under investigation for the treatment of a variety of solid malignant tumors. The technique involves systemic administration of hematoporphyrin derivative (HpD), a photosensitizing compound that is preferentially retained by malignant cells and photoactivation of the neoplasm with red light (630 nm) to achieve selective destruction of cancer cells. We used HpD PRT for seven patients with malignant melanoma of the uvea and conclude that initial results of HpD PRT for uveal malignant melanoma are encouraging and justify further investigation.