Periocular intralymphatic histiocytosis or localized Melkersson-Rosenthal syndrome?

We describe three cases of periocular edema with histopathologic features of intralymphatic histiocytosis without extravascular granulomas. All were elderly males with no other significant medical problems. Previous reports of periocular Melkersson-Rosenthal syndrome are identical clinically, and some reports show illustrations of intralymphatic histiocytosis histopathologically, in addition to other features typical of the syndrome. Given the lack of associated diseases or other features of the Melkersson-Rosenthal triad, some of these cases may be better defined as periocular intralymphatic histiocytosis.

Orbital adherence with titanium mesh floor implants: a review of 10 cases.

BACKGROUND: Multiple materials have been used in the repair of orbital floor fractures. We report 10 cases of complications relating to the use of titanium mesh orbital floor implants. METHOD: A retrospective review of 10 cases in 2 centres in New Zealand. Patients presented with diplopia or eyelid retraction following repair of an orbital floor fracture with titanium mesh implants. RESULTS: Ten patients (7 male, 3 female) aged between 15-78 years old (mean 39 years) presented with significant restriction of eye movement and/or eyelid retraction following repair of an orbital floor fracture with a titanium mesh implant. Seven patients presented with restriction of eye movement alone. Three patients had lower lid retraction in addition to restriction of eye movement. One patient presented with epiphora following erosion of the implant through the nasolacrimal duct. Seven patients underwent surgical removal of the implant with all patients showing improvement of extraocular movement post-operatively. Three cases did not undergo implant removal with one case showing mild improvement over 9 months, and 2 cases showing no improvement. The mean interval between the initial surgery and removal of the implant was 7.1 months. DISCUSSION: In our series, 7 cases required explantation of the original titanium implant. In these cases a vigorous fibrotic reaction had taken place between the orbital contents and the titanium mesh implant. We postulate that the fibrous reaction between the implant and the orbital contents caused the eye movement restriction and the lid retraction. Implant materials used in orbital floor fracture surgery should be inert with a flat profile rather than a mesh to prevent adhesions through the mesh that may cause cicatricial eye movement restriction and eyelid retraction.

Superior oblique muscle palsy after frontal sinus mini-trephine.

OBJECTIVE: The aim of this study is to present a case of superior oblique muscle dysfunction after a frontal sinus mini-trephine. METHODS: This is a case report of an 18-year-old woman where a mini-trephination approach and endoscope were used to open and marsupialize a symptomatic, opacified type IV cell within the left frontal sinus. After surgery, the patient developed a persisting diplopia; a left superior oblique muscle palsy was diagnosed. Nine cadaveric dissections of the trochlea were undertaken to clarify mechanisms for potential trochlear damage. RESULTS: Cadaveric dissection reveals that the trochlea is more than a simple pulley; it is a complex structure in close proximity to the orbital rim. The superior oblique tendon telescopes and is surrounded by a vascular sheath that could be easily traumatized. CONCLUSION: Damage to the trochlea could occur, as the periosteum is elevated from bone or during healing. Alternatively, prolonged traction on soft tissue near the trochlea could cause swelling of the vascular sheath, fibrosis, and hypomobility of the superior oblique tendon. Careful siting of the incision for external frontal sinus surgery as well as careful retraction of skin flaps and periosteal elevation are all techniques used, which should reduce the risk of damage to the trochlea.

The use of fibrin tissue glue in the repair of cicatricial ectropion of the lower eyelid.

PURPOSE: To evaluate the effectiveness of full-thickness skin graft adhesion using fibrin tissue glue (TISSEEL) in cicatricial ectropion repair of the lower eyelid. METHOD: This study was a prospective case series. Nine eyes of 8 consecutive patients with cicatricial ectropion were included. All patients underwent a conjunctival approach lower eyelid retractor plication, lateral tarsal strip, and insertion of a full-thickness skin graft secured with TISSEEL. Symptoms of epiphora, eye and eyelid irritation, discharge, and graft size were recorded pre- and postoperatively. RESULTS: All of the patients were satisfied with their postoperative appearance, and the symptoms of eye and eyelid irritation, discharge, and visual disturbance were eliminated. Fifty-five percent of patients had complained of watering some or all of the time preoperatively, whereas only 33% admitted to occasional watering postoperatively. The average size of the graft reduced by 18% at 1 week, 39% at 1 month, and 40% at 3 months from the initial size. CONCLUSIONS: Fibrin tissue glue used to attach a full-thickness skin graft during cicatricial ectropion repair is an effective technique and may offer additional benefits over sutured graft fixation. Most of the reduction in graft size occurred in the first postoperative month, which indicates that the time window for modulation of the graft is in the first few weeks after surgery. The vertical graft length was affected to a greater extent than the horizontal length.

Determination of the function of a repaired canaliculus after monocanalicular injury by placing a punctal plug in the non-involved punctum on the affected side.

BACKGROUND: To determine whether repair of a monocanalicular laceration using a Mini-Monoka stent provides a functioning system. METHODS: This prospective study included patients who underwent repair of a monocanalicular laceration with placement of a Mini-Monoka stent. Silicone punctal plugs were placed in the unaffected punctum on the side that had sustained the injury and in the same punctum on the fellow eye. The plug was left in place for between 7 and 17 days. The patient was questioned after placement regarding symptoms of epiphora. RESULTS: Eight patients were included in the study; five injuries involved the lower canaliculus, two the upper, and one the upper and lower but only the lower was repaired. Of injuries, 50% were as a result of assault. Seven out of eight patients had no epiphora from the repaired eye during plug placement. One patient complained of significant epiphora from the repaired eye during the time the plugs were placed; this patient had a partial nasolacrimal duct obstruction and no canalicular stenosis. Of patients, 88% had an anatomically patent canaliculus and 100% were tearing-free when no plug was placed. CONCLUSIONS: In this study, a repaired monocanalicular injury provided a functioning system in 88% of cases. In previous studies, it has been shown that many patients are symptom-free with just one functioning canaliculus. However, a fully functioning canalicular system may help to prevent tearing under stress conditions, and will provide a viable system if the other canaliculus is irreparably damaged in the future. Therefore, repair is recommended.

Horizontal skin wound closure in full thickness eyelid excision.

The direct closure of full thickness lid margin defects is well described. The most popular method of closing this defect is to convert it to a pentagon by excising a triangle of skin and muscle below. The resultant scar is perpendicular to relaxed skin tension lines and may be cosmetically obvious. An alternative technique is presented whereby a horizontal subciliary incision is extended either side of the defect. After undermining and minimal excision the skin is closed leaving a horizontal linear subciliary scar, parallel to relaxed skin tension lines.

Clinical controversy: congenital unilateral and jaw-winking ptosis.

Paediatric ptosis is routinely more challenging than adult ptosis with considerations such as amblyopia, difficulty of examination and at what age surgery should be performed. Unilateral severe congenital ptosis and jaw-winking ptosis raise additional questions of which surgical procedure and whether unilateral or bilateral surgery should be performed. A panel of international experts answer questions relating to two clinical scenarios.

Enucleation versus evisceration.

The choice of enucleation and evisceration for removal of an eye remains controversial in certain circumstances. An international panel was asked to give their surgical management of two clinical cases that require either enucleation or evisceration. Case one follows multiple vitreoretinal procedures, and the risk of sympathetic ophthalmia is considered in the surgical management. Case two has had postoperative endophthalmitis, and the possibility of implant infection following insertion of an orbital implant with evisceration and enucleation is discussed.

Dirofilarial infection of the orbit.

PURPOSE: We report on two cases of dirofilaria involving the orbit. There have been no previous case reports of superior rectus involvement in the literature. METHODS: The presenting history, ocular examination, relevant investigations and treatments are discussed. RESULTS: In both cases the lesion was debulked surgically with subsequent histopathological identification of a dirofilarial worm. Postoperatively both patients were relieved of their presenting symptoms with no recurrence of the lesion. CONCLUSIONS: Dirofilarial involvement of the orbit is uncommon. It should be considered as a rare infectious form of specific orbital inflammation and considered in the differential diagnosis of orbital inflammatory lesions.