Nasolacrimal Duct Obstruction Secondary to Eosinophilic Chronic Rhinosinusitis: A Case Report.

A 47-year-old Japanese woman presented with a 1-year history of right-sided epiphora. On initial consultation, the patient had a high right tear meniscus height. CT images revealed bilateral soft tissue opacification in the nasal cavity and maxillary, frontal, and ethmoid sinuses. The lesion in the right nasal cavity and maxillary sinus involved the right lacrimal sac and nasolacrimal duct. Blood test results showed elevated eosinophil count. Endoscopic sinus surgery and excisional biopsy of the nasolacrimal duct were performed. Histopathological examinations of the excised right nasolacrimal duct and nasal polyps from the nasal cavity and maxillary sinus showed high levels of eosinophilic inflammatory infiltrates. The definite diagnosis of eosinophilic chronic rhinosinusitis was made, based on clinical, radiological, and histopathological findings. At 1.5-year follow-up, tear meniscus height was normal, the lacrimal drainage system remained patent, and the rhinosinusitis did not recur.

Practicality and Hemodynamic Advantage of Microvascularly Augmented Pectoralis Major Musculocutaneous Flap: Technical Approach and Evidence Based on Indocyanine Green Angiography.

ABSTRACT: We have recently shown that including the blood flow from the lateral thoracic artery (LTA) in addition to the thoracoacromial artery in the pectoralis major muscle musculocutaneous (PMMC) flap (bipedicle PMMC flap) can increase the perfusion of the flap. We also developed the concept of the supercharged PMMC flap, in which the LTA included in the flap was once cut and anastomosed to a cervical artery under a microscope. It is an effective solution to maintain the additional blood flow from the LTA, when the length of the LTA is compromised for reconstruction. The mandibular reconstruction of an oral cancer patient was performed with a supercharged PMMC flap. Intraoperative indocyanine green angiography was performed in a single pedicle, bipedicle, and supercharged conditions, and the videos were analyzed with a quantitative assessment system of perfusion using some parameters. As a result, blood supply from the LTA was essential for flap survival in this patient, and supercharging from the cervical artery improved flap perfusion compared with the perfusion in the bipedicle condition. The supercharged PMMC flap can resolve the compromise of pedicle length and be also hemodynamically advantageous, thus making the reconstruction more reliable than the conventional technique.

Bilateral Superior Ophthalmic Vein Involvement in a Case With Orbital Sarcoidosis.

A 71-year-old Japanese man presented with a 2-month history of diplopia. He had been followed up at another hospital for ocular sarcoidosis for 3 years. On initial consultation, the best-corrected decimal visual acuity was 0.3 on OU. Slit-lamp and funduscopic examinations were unremarkable. The left lacrimal gland was easily palpable. The patient had restricted infraduction in the OD. MRI showed thickened superior ophthalmic veins on both sides and an enlarged left lacrimal gland. Blood tests showed elevated soluble interleukin-2 receptors. Biopsy of the enlarged lacrimal gland showed numerous epithelioid granuloma and lymphocytic infiltrates consistent with sarcoidosis. No other systemic sarcoidal lesions were detected. The patient started to take prednisolone of 30 mg/day, and the dose was tapered by 5 mg every 2 weeks. At 1 month after taking prednisolone, imaging showed no thickening of the superior ophthalmic veins. At 5 months follow-up, the left lacrimal gland was not palpable, limitation of infraduction improved, and diplopia resolved.

Thickness of the Medial Pretarsal Adipose Tissue in the Upper Eyelid among the Japanese Population.

PURPOSE: To investigate the medial pretarsal adipose tissue thickness of the upper eyelid in the Japanese population. METHODS: Sixty-two whole upper eyelids were harvested from 35 Japanese cadavers and fixed in paraffin. The samples were cut into 5 µm sagittal microsections and stained with hematoxylin and eosin, as well as Masson's trichrome. Data obtained from images and measurements were taken with Aperio ScanScope and ImageScope software and underwent statistical analysis. RESULTS: The samples were divided into 3 shapes sagittal cross-sections of the eyelid (triangular, rectangular, and flat) corresponding to the shape of the medial pretarsal adipose tissue. Type I (triangular shape, 48.4%) had a ratio of fat thickness at 1/2 tarsal height to peak fat thickness of <0.9, and type IIa (rectangular shape, 30.6%) and IIb (flat shape, 21.0%) had pretarsal adipose tissue thickness to tarsal height ratio of ≥0.2 and <0.2, respectively. The mean values of tarsal thickness at 1/2 tarsal height were 1021 µm for the type I group, 1100 µm for the type IIa group, and 764.4 µm for the type IIb group ( p = 0.01). The mean values of fat thickness at 1/2 tarsal height were 410.6 µm for the type I group, 303.3 µm for the type IIa group, and 242.6 µm for the type IIb group ( p = 0.26). CONCLUSIONS: The thickness of the medial pretarsal adipose tissue was different according to the shape of the sagittal cross-section of the eyelid. Awareness of the medial pretarsal adipose tissue thickness contributes to effective suture placement and safe suture depth during blepharoptosis surgery.

Orbital Trapdoor Fracture With Extraocular Muscle Entrapment in Adults: A Case Series.

PURPOSE: To report adult patients with an orbital trapdoor fracture with extraocular muscle entrapment. METHODS: We retrospectively reviewed 566 adult patients (>18 years) with a pure orbital fracture who were referred to us from January 2016 to May 2023. The following data were collected: age, sex, affected side, causes of injury, concomitant ocular injury and nasal bone fracture, presence or absence of oculocardiac reflex and infraorbital nerve hypesthesia, period from injury to surgery, follow-up period, and pre- and postoperative limitation of extraocular muscle motility and fields of a binocular single vision. RESULTS: We found 5 patients (0.9%) with an orbital trapdoor fracture with extraocular muscle entrapment (age range, 19-47 years; all males; 2 right and 3 left). Causes of injury included performing a bench press, fall, assault, boxing, and bicycle accident. Entrapment of the inferior and medial recti muscles was seen in 2 and 3 patients, respectively. None of the patients had any sign of oculocardiac reflex. After surgical reduction, the field of binocular single vision became normal in 3 patients and was incompletely recovered in 2 patients, in whom consultation with us was delayed. CONCLUSION: Adults with extraocular muscle entrapment may not present with an oculocardiac reflex. Urgent release of an entrapped muscle is, however, still recommended to avoid permanent limitation of extraocular muscle motility.

Lacrimal Gland Abscess: A Case Report.

Introduction: The aim of the study was to report a rare case of lacrimal gland abscess. Case Presentation: A 47-year-old woman noticed upper eyelid swelling on the right side 1.5 months before referral to our service. Oral antibiotics were administered, based on the diagnosis of acute dacryoadenitis at another clinic. The symptom had once subsided 20 days later but recurred. On the first examination, the right upper eyelid was swollen with tenderness. The right lacrimal gland was palpable. Blood tests revealed positive proteinase 3-anti-neutrophil cytoplasmic antibody. T2-weighted magnetic resonance and diffusion-weighted images showed a high signal intensity lesion in an enlarged right lacrimal gland, while apparent diffusion coefficient map demonstrated the lesion with a low signal intensity. We started administration of intravenous antibiotics. Abscess drainage and lacrimal gland biopsy were performed 4 days after the first examination. Culture test of the abscess showed only 1 colony growth of Cutibacterium acnes. The specimen harvested from the lacrimal gland showed proliferation of fibrous connective tissue and infiltration of inflammatory cells without vasculitis. After the drainage, the swelling gradually subsided. Administration of antibiotics discontinued at 22 days of follow-up. At 4-month follow-up, the patient did not have any symptom related to the lacrimal gland abscess. Conclusion: The diffusion-weighted images and apparent diffusion coefficient map are helpful for the diagnosis of lacrimal gland abscess when the culture tests provide poor results.

Orbital Langerhans Cell Histiocytosis: A Case Report.

An eight-year-old boy presented with a one-month history of left eyelid swelling. The patient was diagnosed with periorbital cellulitis at another clinic and was treated with oral antibiotics. However, the swelling did not subside. On initial consultation, the patient had left upper eyelid swelling with erythema. His extraocular muscle motility was normal, and the results of blood tests were unremarkable. A computed tomographic scan demonstrated a mass in the superior orbit with destructive changes in the left frontal bone. Histopathological examinations revealed a dense infiltrate of histiocytic cells. Immunohistochemical staining of the tumors for CD1a and Langerin was positive. A pathological diagnosis of Langerhans cell histiocytosis was made. Since orbital Langerhans cell histiocytosis has a high risk for central nervous system involvement, chemotherapy was the treatment of choice for any residual lesion to prevent sequelae to the central nervous system. At the six-month follow-up, the lesion did not recur, and the patient did not experience any central nervous system sequela.

Resection of orbital apex tumours in the medial orbit via four-handed endonasal and transcaruncular approaches.

PURPOSE: To report the surgical outcomes of 4-handed endoscopic and transcaruncular approaches for orbital apex tumours located in the medial orbit. METHODS: This retrospective, observational study included 6 patients (2 males and 4 females; 3 right and 3 left; mean age, 49.5 years; age range, 38-60 years) who underwent excision of an orbital apex tumour in the medial orbit via 4-handed endonasal and transcaruncular approaches. Data on age, sex, affected side, surgical record and complications, and results of pathological examinations, imaging studies, and ophthalmologic examinations were collected. RESULTS: Tumours pathologically corresponded to a cavernous haemangioma in 5 cases and a schwannoma in 1 case. The cavernous haemangioma was completely removed in all cases, while the schwannoma was only debulked because the tumour attached to the surrounding tissues. The medial orbital wall was reconstructed simultaneously in 1 case and 8 days after tumour resection in 1 case. Postoperatively, the visual acuity improved or was maintained in all patients. One patient without medial orbital wall reconstruction showed significant enophthalmos on the affected side after surgery. Another patient without medial orbital wall reconstruction did not obtain binocular single vision field in any direction of gaze after surgery due to severe esotropia. CONCLUSIONS: This report indicates that 4-handed endoscopic and transcaruncular approaches are useful for removal of an orbital apex tumour located in the medial orbit. Medial orbital wall reconstruction after tumour resection may be a better option for reducing the risk of postoperative enophthalmos and esotropia.

Treatment strategies for orbital gas-producing necrotizing fasciitis secondary to odontogenic maxillary sinusitis: Technical notes.

This paper presents treatment strategies for orbital necrotizing fasciitis (NF) in a case of a 33-year-old male diagnosed with orbital NF, which developed after dental root canal treatment. Although orbital NF is rare, it is rapidly progressive and can easily lead to the loss of tissue and visual function, sometimes to a life-threatening extent. Prompt and adequate treatment has been a challenge yet remains quite essential. In addition to the conventional approach to NF, such as immediate antibiotic administration and drainage, orbital NF patients like this case were often treated by incorporating additional steps, which include: 1) performing minimally invasive but adequate removal of necrotic tissue through intraoperative use of ultrasound equipment and postoperative use of proteolytic enzyme-containing ointment for chemical debridement; 2) managing intraorbital pressure by lateral cantholysis and orbital floor removal (decompression); and 3) maintaining the aerobic conditions of the wound after surgical drainage via orbital wall removal. Thus far, satisfactory results in patients with extensive NF of the orbit, including the presented case, were achieved with regards to preserving periorbital tissues, vision, and ocular motility through a multidisciplinary approach. These should be considered as optional means of preserving the orbital tissue and visual function.

Pressure Onto the Orbital Walls and Orbital Morphology in Orbital Floor or Medial Wall Fracture: A 3-Dimensional Printer Study.

The purposes of this study were to compare the pressure onto the orbital floor and medial orbital wall between 3-dimensional printer skull models with unilateral orbital floor and medial orbital wall fractures and to compare the morphology of the orbital floor and medial orbital wall between patients with unilateral orbital floor and medial orbital wall fractures. The skull models were created based on computed tomographic (CT) data obtained from every 10 patients with unilateral orbital floor and medial orbital wall fractures. The orbital spaces of these models were filled with silicone, the silicone surface was pushed down, and pressures onto the orbital floor and the medial orbital wall were measured. On preoperative computed tomographic images taken in the same 20 patients, the superior and lateral bulges of the orbital floor and medial orbital wall were measured, respectively. The measurements were done on the unaffected sides. Consequently, the pressure onto the orbital floor was significantly higher in the orbital floor fracture models than in the medial orbital wall fracture models, although the pressure onto the medial orbital wall was not significantly different between the models. As for the morphologic study, the superior bulge of the orbital floor was higher in the orbital floor fracture group than in the medial orbital wall fracture group. The results of this study indicate that since the orbital floor with a high superior bulge receives high hydraulic pressure, patients with a high superior bulge have a greater risk of orbital floor fracture.

Mechanisms of Development of Orbital Fractures: A Review.

PURPOSE: The purpose of this study is to review the mechanisms in the development of orbital fractures. METHODS: This is a comprehensive literature review that summarizes the mechanisms of developing orbital fractures. RESULTS: There are 3 proposed mechanisms in the development of orbital fractures, which include the buckling, hydraulic, and globe-to-wall contact mechanisms. These mechanisms, as well as patient age, causes of injuries, and periorbital anatomy, influence the extent, sites, and patterns of orbital fractures. CONCLUSION: A deeper understanding of these mechanisms helps us to detect and properly manage orbital fractures in the clinical setting.

Dermolipoma in an Unusual Location: A Case Report and Literature Review.

A healthy nine-year-old Japanese male presented with a history of inferonasal conjunctival mass that was noted to increase in size in a few years' time. Initial examination revealed a 10-mm soft yellowish inferonasal conjunctival mass with a whitish surface. The rest of the examination findings were unremarkable. A computed tomographic scan was done and showed a conjunctival mass that was not connected posteriorly to the orbital fat but had the same density as the orbital fat. Complete surgical excision was performed, and pathologic evaluation of the excised specimen revealed a dermolipoma. The patient was subsequently followed up to monitor for any postoperative complications. Three months following the operation, there was no recurrence of the tumor, and the patient had an excellent cosmetic outcome.

Multiple CD34-Negative Orbital Solitary Fibrous Tumors in a Pediatric Patient.

A 12-year-old Japanese male presented with a 2-month history of headache that was later on associated with diplopia, painless proptosis of the OS, and left ophthalmoplegia. Initial examination revealed a 7-mm OS protrusion, which worsened to 9 mm in less than a month. Preoperative visual acuity worsened from 1.0 to 0.2 with the development of left afferent pupillary defect. Left ocular motility was severely restricted in all directions. Magnetic resonance imaging showed two well-defined lesions adjacent to one another in the left orbit. The patient underwent surgical excision of the left orbital masses. Histopathology findings were consistent with solitary fibrous tumor of the orbit. Immunohistochemistry findings revealed CD34-negative but signal transducer and activator of transcription 6-positive for both specimens. The patient was monitored postoperatively and there was no recurrence of the tumor even after 6 months.

Immunoglobulin G4-Related Bilateral Palpebral Conjunctival Involvement.

The authors show a case with immunoglobulin G4 (IgG4)-related bilateral palpebral conjunctival mass and reviewed 7 similar previously reported cases. Our case was a 42-year-old woman who presented with a 2-year history of a left palpebral conjunctival mass. Pathologic examination of the specimens harvested from the mass revealed marked IgG4-positive plasma cell infiltration. The serum IgG4 level was within the normal limit. Although the mass was completely excised, the lesion recurred 1 month after the surgery, and another new lesion developed in the right upper palpebral conjunctiva. The patient was given 30 mg of oral prednisolone daily, which was tapered gradually. At a 10-month follow-up, the patient continued to take 15 mg of oral prednisolone. The lesions subsided on both sides. On the basis of the literature review, normal serum IgG4 level and upper eyelid lesions may be features of IgG4-related bilateral palpebral conjunctival lesions, and systemic steroids may be effective for this entity.

The Usefulness of Diathermy Thermocoagulation in Chalazion Surgery.

Purpose: To investigate the usefulness of diathermy thermocoagulation in chalazion surgery. Methods: This prospective, observational study included 30 sides from 24 patients who underwent chalazion surgery using diathermy thermocoagulation. The eyelid was fixed with a chalazion clamp under local anesthesia. The skin or palpebral conjunctiva was incised, and the chalazion was partially curetted. The residual chalazion contents were coagulated with diathermy and detached from the surrounding tissues using forceps and scissors. Then, the residual chalazion contents were completely removed. Results: The chalazion was not palpable in all cases 1 week postoperatively. A small chalazion redeveloped close to the primary lesion 2 weeks postoperatively in one patient; however, it spontaneously improved. No other cases experienced recurrence or complication during the follow-up periods. Conclusion: Thermocoagulation of chalazion contents using diathermy facilitates grasp, dissection, and excision of chalazion contents.

Spontaneous regression of immunoglobulin G4-related dacryoadenitis and multiple organ involvement: A case report.

PURPOSE: Immunoglobulin G4 (IgG4)-related dacryoadenitis is rarely resolved spontaneously without steroids. Here, we report a case of IgG4-related dacryoadenitis and extra-ophthalmic lesions with spontaneous regression. METHODS: This is a clinical case report. A 56-years-old man had a 1-year and 7-month-old histories of neck and eyelid swelling, respectively. On the first examination, the lacrimal and submandibular glands were palpable bilaterally. Computed tomographic images showed enlargement of the lacrimal gland on both sides, right pulmonary hilar lymph node, and pancreas, and thickening of the abdominal aortic wall. Blood tests demonstrated elevated serum IgG4 level and positive hepatitis B surface antibody. Pathological examination of the biopsied lacrimal gland specimens revealed marked IgG4-positive plasma cell infiltration. RESULTS: The patient was monitored carefully without steroid administration. Serum IgG4 level had gradually decreased during follow-up period and reached the normal range 3 years after the biopsy. At 4-year follow-up, the lacrimal and submandibular glands were not palpable on either side. Computed tomographic images demonstrated no enlargement of the lacrimal gland, submandibular gland, or lymph nodes, and improvement of the enlarged pancreas and thickened abdominal aortic wall. CONCLUSION: Our case indicates that careful observation can be an option in selected cases with risks of steroid treatment or silent clinical course.

Severe corneal involvement secondary to congenital lower eyelid epiblepharon.

PURPOSE: The study aims to examine an incidence and risk factors of severe corneal involvement in patients with congenital lower eyelid epiblepharon. METHODS: This retrospective, observational study included 509 patients (933 eyes) with congenital lower eyelid epiblepharon. Data on age, sex, affected side, past history, past surgery, presence or absence of concomitant periocular/ocular diseases, body height and weight, astigmatic power, and corneal involvement were collected. Severe corneal involvement included corneal scarring, vascularization, and perforation. RESULTS: Severe corneal involvement was found in 30 patients (5.9%) (34 eyes, 3.6%). Corneal scarring and perforation with scarring were shown in 29 patients (33 eyes) and 1 patient (1 eye), respectively. Nine patients (12 eyes) demonstrated concomitant corneal vascularization with corneal scarring. Logistic regression analysis showed that body mass index had an odds ratio of 1.057 (P = 0.078). Age and sex did not affect occurrence of severe corneal involvement (P > 0.050). CONCLUSIONS: In this study, 5.9% of patients showed severe corneal involvement in congenital lower eyelid epiblepharon. Logistic regression analysis indicates that a high body mass index was a possible risk factor of severe corneal involvement caused by congenital lower eyelid epiblepharon.

Reliable and safe salivary duct repositioning technique with partial transection and intraductal stenting: Technical notes.

Salivary duct repositioning is often performed after excision of malignant tumors or removal of sialoliths to maintain salivary function and minimize the risk of swelling or pain due to the obstruction of the gland. However, there is risk of intraoperative tissue damage due to traumatic manipulation, leading to stenosis; in addition, the small diameter of the duct also renders this procedure difficult. Recently, we improved our method of salivary duct repositioning as follows. In the first technique, partial transection is made on the lateral wall of the duct ligated with thread at the end. Pulling the thread provides a view of the lumen, and appropriate tension enables a reliable and non-invasive procedure without requiring the operator to grasp the edge of the duct directly. When the diameter of the duct is small, intraductal stenting, the second technique, can be combined with the former technique by probe insertion to expand the lumen. Our approach is technically easy and simple which can be accepted by any clinicians and it could also be a promising technique that can serve as a less invasive and effective treatment.

Bilateral acquired canaliculops: Report of two cases.

We report two rare cases of bilateral acquired canaliculops. A 67-year-old woman and an 89-year-old man showed cystic lesions in the medial-upper eyelid on both sides. In both of the cases, re-canalization using dacryoendoscopy was failed because of firm obstruction at the canaliculus and/or junction between the lacrimal sac and nasolacrimal duct. Although 15 cases with canaliculops had been reported previously, only one congenital case showed bilateral canaliculops. The results of our study indicate more complex obstruction in cases with bilateral canaliculops compared to those with unilateral canaliculops.

Lymphoproliferative disorders in the lacrimal caruncle: report of three cases and review of literature.

This report included three cases of lymphoproliferative disorders developing from the lacrimal caruncle. The first case was an 11-year-old boy with reactive lymphoid hyperplasia in the left lacrimal caruncle. The second case was an 80-year-old woman with reactive lymphoid hyperplasia in the right lacrimal caruncle. The third case was a 77-year-old man with follicular lymphoma in the left lacrimal caruncle. Our literature review of cases with lacrimal caruncular lesions showed 11 reported cases with reactive lymphoid hyperplasia and 17 with malignant lymphoma. There had been no previous report on follicular lymphoma in the lacrimal caruncle.