Congenital lacrimal fistulas.

Twenty-one patients had surgical procedures for symptomatic cogenital lacrimal fistulas. The symptoms were epiphora from birth in 18 patients and late-onset epiphora in three cases. Thirteen patients had nasolacrimal obstruction at the upper duct or sac level. There were 21 dacryocystorhinostomies with fistula excision and canalicular intubation, and one patient had excision of the fistula tract only. The fistulas originated from the tear sac in only four cases and from the common canaliculus in 17; in one, the upper and lower canaliculus and the lacrimal fistula each had a separate opening into the lateral sac wall. The functional success rate was 95%. We recommend dacryocystorhinostomy with common canalicular dissection, fistula excision, and canalicular intubation for all patients with symptomatic congenital lacrimal fistulas to facilitate outflow and to avoid common canalicular obstruction.

Orbital optic nerve glioma in adult life.

In seven cases, optic nerve glioma presented as an expanding orbital mass in previously asymptomatic adults. Clinically and histologically, these tumors were similar to the orbital optic nerve gliomas of childhood; in contrast to the rapidly progressive malignant gliomas of the chiasm well described in adults, the patients with these tumors had a more benign clinical course. Management of optic nerve glioma in adulthood should be conservative in the presence of useful vision.

Ganglioglioma of the optic nerve.

We examined a 15-year-old boy who had a ganglioglioma involving the left optic nerve, which caused proptosis, decreased vision, and optic atrophy. Computed tomography demonstrated an intraconal mass along the course of the orbital portion of the optic nerve. The only evidence of systemic neurofibromatosis was axillary freckling. The patient underwent a combined medial and lateral orbitotomy and excision of the tumor. Histologic examination demonstrated a mass composed of neurons and glial cells characteristic of ganglioglioma. After a one-year follow-up period, we have found no evidence of recurrence.

Orbital cellulitis.

Forty-nine cases of orbital cellulitis were reviewed. The average age of patients at presentation was 31 years. The onset of symptoms varied from seven days or less in 28 patients, one to four weeks in 17 patients, and more than four weeks in four patients. The leucocyte count, available in 33 patients, was greater than 10 X 10(9)/l in only nine. Abnormal sinuses were noted radiographically in 61%. Computed tomography scans, performed on nine patients, revealed non-localised inflammation in three and an orbital mass in six. Cultures, in general, were disappointing. Seventeen surgical procedures were performed on 14 patients. The complications of orbital cellulitis, occurring in five patients, included osteomyelitis of the maxillary bone, strabismus, afferent pupillary defect, chronic draining sinus, and scarred upper eyelid. Usually the treatment of orbital cellulitis requires aggressive parenteral antibiotic therapy and judicious surgical intervention.

Blepharochalasis.

Blepharochalasis is an uncommon disorder distinguished by recurrent episodes of eyelid oedema in young patients. A hypertrophic form, manifested as fat herniation, and an atrophic form, manifested as fat atrophy, have been described. Ptosis with excellent levator function, laxity of the lateral canthal structures with rounding of the lateral canthal angle, nasal fat pad atrophy, and redundant eyelid skin develop after many episodes of eyelid swelling. Fine wrinkling, atrophy, and telangiectasias characterise the excess eyelid skin. We describe four cases of this syndrome in which external levator aponeurosis tuck, blepharoplasty, lateral canthoplasty, and dermis fat grafts were used to correct atrophic blepharochalasis after the syndrome had run its course.

Nasal heterotopia of the macula with persistent hyaloid vessel.

A 22-year-old woman presented with nasal dragging of the disc and nasal ectopia of the macula due to persistent hyaloid vessels. The causes of this entity are presented. Patients with strabismus should have ophthalmoscopic fundus exam to rule out ectopic maculae.

Lumps and bumps of the eyelids and their management.

BACKGROUND: Tumors of the eyelids, because of their location and variety, can present management problems. OBJECTIVE: To describe tumors of the eyelid, their identification, and their management. CONCLUSION: All tumors and inflammations of the lids, except those that are easily diagnosed, should be biopsied and sent for histologic administration.

Congenital see-saw nystagmus associated with retinitis pigmentosa.

Two sibling patients with see-saw nystagmus associated with advanced retinitis pigmentosa are presented. The see-saw nystagmus was most likely congenital but demonstrated a torsional pattern different from that previously reported for congenital see-saw nystagmus. Anatomic and etiologic factors associated with see-saw nystagmus are discussed.

Aneurysmal bone cyst of the orbit.

Proptosis of the left eye had developed in a 42-year-old woman for 2 months' duration. Roentgenogram studies showed a mass in the roof of the left orbit and bone erosion. An excisional biopsy confirmed the presence of an aneurysmal bone cyst. To the authors' knowledge, the patient is the oldest reported patient who has this uncommon orbital lesion.

Natural history of the congenital eyelid tetrad (Komoto's syndrome).

The congenital eyelid tetrad (CET) comprises epicanthal folds, telecanthus, ptosis, and blepharophimosis. The natural history of CET is that with time the epicanthal folds disappear and the telecanthus becomes insignificant, but the ptosis and the blepharophimosis remain functional and cosmetic problems. Surgical correction of the ptosis and the blepharophimosis should be performed early in the patient's life, but surgical correction of the telecanthus and epicanthal folds should be deferred until growth is complete when such surgery may not be necessary.

Results of blepharoptosis surgery with early postoperative adjustment.

The authors reviewed 157 cases (207 eyes) of blepharoptosis corrected by external levator resection. Twenty-eight patients (29 eyelids) had unsatisfactory results. The authors adjusted 13 eyelids within 1 week of surgery. Eleven eyelids were reoperated 6 or more weeks after surgery. The mean delay between the initial and final surgery in the early group was 2.0 weeks; and, for the late group, 33.5 weeks. For those having reoperations, there was no difference in the number of procedures required to achieve satisfactory outcomes. Four patients (5 eyelids) with unsatisfactory results were offered, but declined, late repair. Early or late reoperation is effective in correcting unsatisfactory results after external levator resection. The benefits of early surgery are a reduction in time to final result, the ease with which it is performed, potential cost savings, and the opportunity one has to correct unsatisfactory results.

Intralesional 5-fluorouracil for keratoacanthoma of the eyelid.

Keratoacanthoma of the lower eyelid developed in two patients. In the first case, conventional excision biopsy necessitated a large eyelid reconstruction procedure. In the second case, 5-fluorouracil was injected into the base of the keratoacanthoma. Both treatments resulted in complete resolution of the lesion with excellent cosmesis. Thus, intralesional 5-fluorouracil can be useful for keratoacanthomas of the eyelid in patients who are not good candidates for surgery.

Chronic hematic cyst of the orbit.

Three middle-aged male patients had painless superior temporal orbital tumor causing globe displacement. Roentgenograms revealed superior temporal orbital tumor with lysis of bone. Surgical excision and curettage completely removed the lesions, which extended from the frontal bone to the periorbita and the dura. Histologically, these were cystic lesions containing a granulomatous reaction to blood breakdown products, including cholesterol clefts, hemosiderin, giant cells, and hematodin, consistent with chronic hematic cyst. A fibrous pseudocapsule formed the cyst wall.

Fitting of the dermis-fat grafted socket.

Anophthalmic orbits that reject conventional implants may accept the dermis-fat graft. The subsequent fitting of such a socket differs in many important ways from the fitting of sockets containing conventional implants. Before surgery, the ocularist should construct a custom-made scleral ring to be inserted after the operation. This replaces the standard conformer that can erode the underlying dermis. The socket must be observed carefully for any evidence of damage to the conjunctiva-dermis suture line by the ring, and the latter modified or replaced as necessary. Granulation tissue forming around the sutures uniting conjunctiva and dermis may have to be resected and cauterized. Impression molding of an artificial eye is performed five weeks after surgery. The artificial eye always requires modifications over the first six months as the graft recedes due to partial atrophy of the fat of the graft, thus deepening the socket.

Management of complications following dermis-fat grafting for anophthalmic socket reconstruction.

Sixty consecutive cases of dermis-fat grafts for anophthalmic socket reconstruction were reviewed to examine the frequency, severity, and management of postoperative complications. In seven patients, the conjunctiva failed to resurface the graft and central ulceration developed. Ten cases resulted in enophthalmos. Two patients developed keratinized sockets with chronic discharge and desquamation. Three patients required excision of conjunctival granulomas. One patient developed a primary graft infection. A donor site hematoma occurred in one patient. Secondary surgical intervention was required in ten patients. Nine complications in eight patients were managed in the office; five complications in four patients were observed and subsequently resolved without surgical intervention. Most complications occurred in patients with severely traumatized sockets who had undergone extensive earlier ocular surgery, or who had a systemic disease contributing to defective wound healing.

The tarsal pillar technique for narrowing and maintenance of the interpalpebral fissure.

We describe a tarsorrhaphy technique whereby an ipsilateral upper-eyelid tarsal pillar is sutured to a corresponding lower-eyelid recipient site. This technique allows maintenance of a narrowed interpalpebral fissure indefinitely, yet is easy to reverse without incurring lid-margin damage. Additionally, the procedure can be adjusted postoperatively to either narrow or widen the initial surgical result. We report our combined surgical experience in 35 consecutive procedures using this technique to treat eyes with exposure-related keratopathy of varied etiology, including facial nerve palsies, combined facial nerve palsy and trigeminal neuropathy with an anesthetic cornea, Graves' disease, congenital craniofacial anomalies, and severe keratitis sicca syndrome. The procedure was successful in improving exposure keratopathy symptoms in all 35 cases. Complications, reflecting the authors' learning curve with this new procedure, included intermarginal pyogenic granulomas, stretching of the tarsal pillar, minor lower-eyelid-margin eversion, and tarsal pillar dehiscence.