Contemporary management of orbital blowout fractures.

PURPOSE OF REVIEW: Orbital floor blowout fractures may lead to significant morbidity, including debilitating double vision and globe malposition. Thorough evaluation and timely surgical intervention may prevent long-term sequelae. RECENT FINDINGS: New studies have demonstrated certain patients with orbital floor fractures to do well when managed conservatively. In those necessitating operative repair, precise surgical dissection and adequate fracture reduction are essential to restoring orbital anatomy and function. Novel surgical techniques and orbital floor reconstruction materials, described in this review, will further optimize patient outcomes. SUMMARY: A knowledgeable evaluation, thoughtful management strategy and modernized surgical technique can prevent long-term disability in patients with orbital floor blowout fractures.

Transposition Upper Blepharoplasty With Orbital Retaining Ligament Release.

PURPOSE: Volume restoration is an important component of aesthetic facial rejuvenation, particularly in the brow and upper eyelid regions. In this study, the authors describe transposition of the central, preaponeurotic fat pad in the sub-brow preperiosteal plane with full release of the brow during upper blepharoplasty. METHODS: A retrospective review including all patients who underwent transposition of the upper eyelid central, preaponeurotic fat pad at the time of upper blepharoplasty. Patients with simultaneous brow lifting surgeries were excluded. The surgical technique involved placement of the preaponeurotic fat pad pedicle in the sub-brow space after full brow release for augmentation of sub-brow volume after performing upper blepharoplasty. RESULTS: Nineteen patients (n = 36 eyelids) were identified who underwent this transposition upper blepharoplasty technique. No complications or adverse events related to this procedure were observed. All patients were satisfied with their outcome. CONCLUSIONS: Transposition upper blepharoplasty with complete brow release is a safe, effective adjunct to blepharoplasty for upper eyelid and periorbital rejuvenation.

MEN 2B masquerading as chronic blepharitis and euryblepharon.

This is a retrospective case description of a single male patient found to have multiple endocrine neoplasia syndrome type 2B (MEN 2B). At the age of 14, he presented for evaluation of ocular irritation and eyelid thickening. Intraoperative assessment revealed mucosal lesions on the anterior dorsum of his tongue and biopsy of multiple eyelid lesions disclosed bilateral submucosal neuromas, leading to the diagnosis of MEN 2B. MEN 2B is a potentially life-threatening syndrome due to the risk of developing medullary thyroid carcinoma (MTC) and pheochromocytoma. The patient was found to have MTC requiring thyroidectomy. We hope to highlight the clinical and histopathologic findings of MEN 2B in an effort to emphasize the importance of its identification in the absence of a family history.

A CASE OF INTRAVESICAL BACILLUS CALMETTE-GUERIN-RELATED ENDOPHTHALMITIS AND RETINITIS CONFIRMED WITH RETINAL BIOPSY.

PURPOSE: To present a rare case of bilateral endogenous chorioretinitis and unilateral endophthalmitis due to Mycobacterium bovis in a patient who received intravesical bacillus Calmette-Guerin (BCG) treatment. METHODS: We present a case of a single male patient with bilateral endogenous chorioretinitis due to Mycobacterium bovis in a patient who received intravesical BCG, an attenuated strain of M. bovis widely used to treat superficial bladder cancer. The patient underwent intravitreal tap, vitrectomy, and chorioretinal biopsy with histologic examination. RESULTS: The patient presented with a visual acuity of light perception in the right eye and 20/25 in the left eye. Examination of the right eye revealed dense vitreous haze, whereas the left eye demonstrated multifocal, yellow, round subretinal pigment epithelial lesions in the macula. The patient underwent a vitreous tap with injection of antibiotics and was admitted to the hospital for empiric systemic antibacterial and antifungal treatment along with an endogenous endophthalmitis workup. His systemic evaluation and vitreous tap did not identify a causal organism, and the eyes failed to improve on empiric therapies. He underwent pars plana vitrectomy and retinal biopsy of the right eye that revealed vitreal and infiltrative retinal acid-fast bacilli. Cultures confirmed M. bovis to be susceptible to ethambutol, rifampin, and isoniazid. After starting antimycobacterials, his vision improved to finger counting in the right eye, and his vision and appearance of the lesions remained stable in the left eye at postoperative month one. CONCLUSION: Intravesical BCG stimulates a local cell-mediated response that destroys malignant cells. It is generally well tolerated, although it rarely can result in secondary systemic infection. Intravesical BCG-related endophthalmitis is rare and should be considered in the setting of ocular inflammation in patients with a history of bladder cancer who may not disclose previous treatment with BCG.

Orbital T-cell lymphoma versus lupus panniculitits: a T-cell-mediated spectrum of orbital lymphoproliferative disease.

This is a case description of a single male patient found to have T-cell-mediated inflammation and lymphoproliferation of the orbit. Chronic T-cell-mediated inflammatory disease can pose a diagnostic challenge particularly in its differentiation from a neoplastic process. The histopathology in this case demonstrated features of both lupus erythematosus panniculitis and features of orbital T-cell lymphoma. While both are rare, lupus erythematosus panniculitis of the orbit is even more exceptional; this patient's indolent, chronic relapsing course distinguished itself from the typical aggression of orbital T-cell lymphoma. We believe this rare case may actually represent an example of a newly described disease spectrum that incorporates lupus erythematosus panniculitis as well as subcutaneous panniculitis-like T-cell lymphoma.

Basaloid adenocarcinoma of the lacrimal sac: A rare entity and approach to management.

Presented is a rare case of basaloid adenocarcinoma of the lacrimal sac. Low grade features of this malignancy permitted a conservative surgical approach to maximize functional and cosmetic outcomes. This is retrospective case description of a single 77-year-old-female patient who underwent a dacryocystorhinostomy with silicone tubes at an outside hospital for epiphora, but was referred to the Wills Eye Hospital Oculoplastics Department for a lacrimal sac biopsy showing low-grade carcinoma with basaloid features. She was treated with complete excision of the mass, common canaliculus and distal canaliculi, and the nasolacrimal duct. The associated maxillary, lacrimal, and ethmoidal bones were similarly excised. Frozen sections were sent of the surrounding periosteum, orbital fat, nasal and sinus mucosa, and soft tissues, and all were negative. Reconstruction of the lacrimal system was performed with silicone tube intubation and the defect was closed with large glabellar and mid-facial flaps. One year post-operatively she maintained a normal ocular examination, and her eyelids and silicone tubes were well positioned. Systemic evaluation remained unrevealing. Basaloid adenocarcinoma of the lacrimal sac is relatively rare, and we highlight the role of a more conservative surgical intervention given the high rates of survival and low incidence of progression to metastatic disease when treating this rare malignancy.

A case of concurrent silent sinus syndrome, thyroid eye disease, idiopathic orbital inflammatory syndrome, and dacryoadenitis.

This is a retrospective case description of a single female patient found to have concomitant bilateral silent sinus syndrome, bilateral thyroid eye disease, unilateral dacryoadenitis, and idiopathic orbital inflammation that presented as progressive unilateral right-sided proptosis. The spectrum of inflammatory orbital diseases can make discerning between different entities challenging, but more unique in this case was the simultaneous presentation with bilateral silent sinus syndrome, a rare entity in its own right. Identifying each of these concurrent disease processes is important to establishing a multidisciplinary treatment approach to address all the patient's orbital and peri-orbital pathology. We hope to highlight the clinical and radiographic findings unique to each of these entities and share our approach to treatment in this complex case.

Ocular Adnexal Reconstruction for Cutaneous Periocular Malignancies.

Although the majority of lesions present in the periocular region are benign, periocular cutaneous malignancies are certainly not uncommon and must be considered. The management of nonmelanoma cutaneous malignancies is predominately surgical with Mohs micrographic surgery or excision with frozen sections. The approach to reconstruction of the resulting defects depends on the defect location and size. When able, it is preferable to close lesions directly or with the recruitment of adjacent tissue in an effort to preserve the inherent anatomy. The eyelid's dynamic function is thus maintained, which is essential for optimal ocular surface protection. However, larger and more extensive defects will require complex reconstructions that are able to restore the necessary structural integrity to the eyelids. The authors review the various reconstruction approaches for defects of all sizes involving the periocular area including nonmarginal defects and defects of the lower and upper eyelids, as well as those of the medial canthal region.

Clinical Evaluation of Blepharoptosis: Distinguishing Age-Related Ptosis from Masquerade Conditions.

Aponeurotic ptosis accounts for the majority of acquired ptosis encountered in clinical practice. Other types of ptosis include traumatic, mechanical, neurogenic, and myogenic. In addition to true ptosis, some patients present with pseudoptosis caused by globe dystopia, globe asymmetry, ocular misalignment, or retraction of the contralateral lid. It is particularly important for the clinician to rule out neurologic causes of ptosis such as dysfunction of the third cranial nerve, Horner's syndrome, and myasthenia gravis, as these conditions can be associated with significant systemic morbidity and mortality. A thorough history and physical examination is necessary to evaluate each patient presenting with a complaint of ptosis. Correctly identifying the cause of the patient's complaint allows the ptosis surgeon to plan for appropriate surgical repair when indicated and to defer surgery when observation or additional clinical evaluation is warranted.

Solitary Extramedullary Plasmacytoma of the Orbital Apex and Dura Masquerading as Idiopathic Inflammation.

This is a retrospective case description of a single female patient found to have a primary solitary extramedullary plasmacytoma of the orbital apex and temporal/parietal dura. These monoclonal plasma cell neoplasms account for fewer than 5% of plasma cell neoplasms. Although most commonly found in the head and neck, orbital and dural solitary extramedullary plasmacytomas are extremely uncommon. The authors present a case of an extramedullary plasmacytoma involving both of these structures in a middle-age otherwise healthy female to highlight this rare entity and elucidate current treatment modalities and future considerations.