Levator lengthening by marginal myotomy.

A surgical procedure has been designed for lengthening the levator aponeurosis by two partial-width (marginal) myotomy incisions. This operation does not require complete division or disinsertion of the levator, Müller's muscle, or tarsus. No foreign materials or sclera need to be inserted into the lid. The procedure has been used to treat upper lid retraction due to ophthalmic Graves' disease and for eyelid reconstruction after resection of basal cell carcinoma that involves the lid margin. Since an anterior incision is made through the skin, adhesions between the levator aponeurosis and the overlying tissues may be divided in patients with Graves' disease.

Choroidal folds and refractive errors associated with orbital tumors. An analysis.

Twenty patients with unilateral exophthalmos secondary to orbital tumors underwent fundus photography; 16 underwent fluorescein angiography. Choroidal folds were found in 15 eyes. The location of each tumor with respect to the globe was determined by computed tomography. In addition, most patients underwent B-scan ultrasonography and surgical exploratory procedures. Choroidal folds were more common in patients with greater amounts of exophthalmos and with anteriorly located tumors. Moreover, the pattern of choroidal folds generally reflected the location of the tumor within the orbit. Comparison with the uninvolved fellow eyes showed that preoperative refractive errors were usually shifted toward hyperopia with intraconal tumors, whereas extraconal tumors were typically associated with higher astigmatic errors on the involved side.

A method for combined dacryocystorhinostomy with external ethmoidectomy.

Severe polypoid rhinosinusitis requiring external ethmoid surgery may be seen in conjunction with partial or complete nasolacrimal obstruction. When this obstruction is associated with persistent, unresolved lacrimal symptoms, it is sometimes appropriate to combine surgical procedures, thereby avoiding separate lacrimal surgery. A method combining dacryocystorhinostomy (DCR) with external ethmoidectomy is described. The anatomy involved in this procedure and the indications for it are discussed.

Cicatricial ectropion and lacrimal obstruction associated with the sclerodermoid variant of porphyria cutanea tarda.

A patient with porphyria cutanea tarda developed bilateral cicatricial ectropion with stenosis of the puncta and canaliculi. The pathophysiologic findings suggested a photosensitivity reaction in sites of uroporphyrin and 7-carboxyl porphyrin deposition.

Merkel cell carcinoma of the eyelid and periocular tissues.

Five patients had eyelid and periocular Merkel cell carcinoma. The tumor was located on the left lower eyelid in two patients, the left upper eyelid in one patient, the right upper eyelid in one patient, and was metastatic to the right outer canthus in one patient. The mean duration of symptoms was approximately four months. The diagnosis of Merkel cell carcinoma was not suspected clinically in any of the four primary eyelid cases, but was only established on histopathologic examination of biopsy specimens. Light microscopy disclosed carcinoma with small primitive cells in all five tumor biopsy specimens. Immunohistochemical studies showed neuron-specific enolase and keratin and transmission electron microscopy demonstrated neurosecretory granules typical for Merkel cell carcinoma. All five patients in this study were treated with wide surgical excision of the eyelid tumors with intraoperative frozen-section monitoring of the margins of resection. The left lower eyelid Merkel cell carcinoma spread to the preauricular lymph node in one patient. This patient subsequently died of metastatic Merkel cell carcinoma. One patient with metastatic right outer canthus Merkel cell carcinoma received radiotherapy (6,550 cGy). Eyelid Merkel cell carcinoma has the potential for recurrence and metastatic spread. We recommend lifetime follow-up for patients treated for eyelid Merkel cell carcinoma.

Orbital fracture evaluation by coronal computed tomography.

Coronal computed tomography produces orbital scans in a plane that is analogous to Caldwell-view x-ray films. Coronal computed tomography permits simultaneous visualization of the orbital walls and the orbital soft tissues, including all extraocular muscles. Using coronal computed tomography, we studied a series of patients with radiographically proven orbital floor fractures. We studied in detail three of these patients, one with a linear orbital floor fracture, one with a depressed orbital floor fracture, and one with a severely comminuted orbital floor. In two patients, coronal computed tomography showed inferior rectus muscle entrapment, which was confirmed at the time of surgery. In each patient, some bone fragments could be seen more discreetly on coronal computed tomography than on conventional polytomes. Coronal computed tomography may be used to help confirm extraocular muscle entrapment in patients with orbital floor fractures. Coronal computed tomography can also be used to examine patients with possible intraorbital foreign bodies, unexplained reduction of vision, or severely displaced bone fragments.

Hepatoma metastatic to the orbit.

A 69-year-old man with a history of cirrhosis of the liver had unilateral progressive proptosis without jaundice, abdominal pain, or gastrointestinal symptoms. Results of laboratory and radiographic studies were also normal. Orbital biopsy revealed hepatocellular carcinoma. Although hepatocellular carcinoma has often been shown to metastasize to the brain and often to the flat bones of the skull, to the best of our knowledge, this is the first histologically proven case of hepatoma metastatic to the orbit.

Detection of human papillomavirus DNA sequences in conjunctival papilloma.

Two histologically proven conjunctival papillomas (one from a 33-month-old boy and the other from a 28-year-old woman) were examined for the presence of papillomavirus by DNA molecular hybridization. The first case, a recurrent tumor known to be positive for papillomavirus structural antigen, demonstrated human papillomavirus DNA sequences that cross-hybridized to a human papillomavirus type 11 DNA probe. The second case, an initial tumor, which was negative for papillomavirus structural antigen, demonstrated no viral DNA sequences by hybridization.

Interferon-alpha therapy of recurrent conjunctival papillomas.

Five patients with multiple, recurrent conjunctival papillomas underwent surgical excision of their tumor and then received interferon alpha-N1, 5 X 10(6) units/m2 (5 Mu/m2), intramuscularly daily for one month. A similar dose was given two to three times per week for the next six months and tapered off or discontinued thereafter. The follow-up period varied from one to four years. Two patients have had no recurrence of tumor. The other three patients have had recurrences of lesser severity upon tapering or discontinuing the interferon, and repeat surgical or laser excision of these lesions has been performed. The presence of koilocytosis and human papillomavirus type 11a DNA sequences was noted in all specimens large enough to examine, whereas papillomavirus structural antigens were detected in only two of five specimens. A regimen of interferon therapy appears to be tumor suppressive, but not curative.

Rhinoscleroma with exophthalmos: a case report.

This is a report of a 20-year-old Nigerian man with a 15-year history of exophthalmos and nasal blockage caused by rhinoscleromatous. The diagnosis was made by histopathological examination of a biopsy specimen taken from the nasal passages. Despite protracted antibiotic therapy the patient experienced recurrent exophthalmos. Computerised axial tomography and sinus films showed the lesion to have invaded through the sinus passage into the orbit. Further histopathological examination of tissue removed at the time of surgical decompression also revealed rhinoscleroma. This appears to be the third report of rhinoscleromatous spread to the orbit.

Melanomas of the conjunctiva.

Conjunctival melanomas are much less common than custaneous melanomas. Consequently, the classification and treatment of these mucosal tumors is more controversial than that of skin tumors. Conjunctival melanomas can be simply classified into tumors that are superficial and develop in a radial-growth phase, and those that are invasive and develop in a vertical-growth phase. By careful histological examination the maximum tumor thickness can be measured and the presence of the tumor within conjunctival epithelium, the substantia propria, or deeper tissues can be determined. Superficial tumors, tumors with a total radial-growth phase, tumors thinner than 0.76 mm., tumors confined to the conjunctival epithelium, and tumors near the corneal limbus seem to have a favorable prognosis. The fact that a conjunctival melanoma arises in an area of acquired melanosis, arises in association with a nevus, or arises de novo has not been definitely proved to be of prognostic significance. Treatment of conjunctival melanomas should be preceded by biopsy and histological confirmation of the diagnosis. Systemic evaluation should include examination of regional lymph nodes, chest roentgenograms, liver scans, and liver function tests. The eye and the complete conjunctival surface should be carefully examined, photographed, and drawn. The commonly accepted treatment of stage I melanomas of the skin or conjunctiva is surgical removal of the malignant tissue. Superficial and minimally invasive tumors near the corneal limbus may sometimes be excised with en bloc resection of the adjacent superficial cornea and sclera. Treatment of any malignant tumor must be somewhat individualized. Melanomas involving the fornices and eyelids may be treated by complete excision or by exenteration. Exenteration seems to be a reasonable plan in patients with extensive or bulky tumors. The role of prophylactic regional node dissection has not been established for patients with conjunctival melanomas. Similarly, adjunctive chemotherapy, immunotherapy, and hormone therapy are of unknown value in the management of stage I tumors of the conjunctiva. Cryotherapy and radiation therapy have been used only in small numbers of patients with conjunctival melanomas. The choice of these treatments instead of surgical excision in the management of such tumors should be highly selective.