Analysis of eyelid fat pad changes with aging.

PURPOSE: Few studies have focused on the aging changes in the upper eyelid. This study evaluated the differential changes in the nasal and central fat pads of the upper eyelid associated with aging. METHODS: In this retrospective, consecutive series, the medical records and photographs of 77 patients were reviewed. The patients were grouped in 7 categories according to decade of life. Using a standardized scale, the volume grade of the nasal and central fat pads was graded from 0 to 3. Statistical evaluation correlating age with central and nasal fat pad change was performed. RESULTS: With aging, the central fat pad volume appeared to diminish, with relative sparing of the nasal fat pad. There was a positive correlation of the volume grade of the nasal fat pad with age and a negative correlation of the central fat pad with age. In addition, there was a statistically significant difference between the volume grades of the nasal and central fat pads in the groups 70 years and older. CONCLUSIONS: With aging, there appears to be a pattern of differential fat pad alteration. This study shows that in the upper eyelids of patients >70 years of age, the medial fat pad becomes prominent whereas the central fat pad atrophies. Teleologically, the relative preservation of nasal fat may be due to its higher abundance of neural-crest progenitor cells. Clinically, this finding has implications in esthetic and functional upper eyelid blepharoplasty.

Primitive neuroectodermal tumor of the orbit in adults: a case series.

PURPOSE: To present the clinical, radiologic, and histopathologic features of orbital primitive neuroectodermal tumor (PNET) in 5 adult patients. METHODS: Retrospective case series of 5 adult patients with orbital PNET. Orbitotomy was performed in all cases. The authors report clinical findings, radiologic features, histopathology, immunohistochemical analysis, management, and outcomes for 5 patients with orbital PNET. RESULTS: Five adult patients presented with progressive unilateral proptosis and visual impairment. Common radiographic findings included a heterogeneous mass without associated destructive features, located in the superior and/or lateral orbit. Four cases demonstrated strong immunohistochemical staining for CD99 in a membranous pattern. One case required chromosomal analysis with fluorescence in situ hybridization to confirm the diagnosis. All patients received chemotherapy and/or orbital radiation with resolution of proptosis but no improvement of vision. One patient died of disease. CONCLUSIONS: To the authors' knowledge, this is the largest series of orbital PNET in adults. This tumor has an age demographic wider than previously believed and should be considered in the differential diagnosis of a hypercellular small round cell orbital tumor in both children and adults. Current treatment regimens are not standardized but typically use a similar approach to the treatment of Ewing sarcoma. Orbital PNET appears to have less propensity for metastasis compared with PNET in other locations. However, long-term aggressiveness remains to be proven.

Radiographic analysis of extraocular muscle volumetric changes in thyroid-related orbitopathy following orbital decompression.

PURPOSE: To evaluate radiographic volume changes in extraocular muscles (EOM) following orbital decompression for thyroid-related orbitopathy (TRO). METHODS: Medical records of 22 orbits in 12 patients undergoing postoperative orbital CT after orbital decompression for TRO were retrospectively reviewed. All orbits demonstrated no signs of clinical reactivation of TRO. EOM volumes were determined by the summation of each EOM's cross-sectional area in the coronal plane of the CT scans and multiplying the sum by the slice thickness. Main outcome measure was a comparison of EOM volumes preoperatively and postoperatively. RESULTS: All orbits demonstrated proptosis reduction postoperatively with a mean of 4.8 mm +/- 2.1 mm (p < 0.0001). The significant increase in the medial rectus muscle (p = 0.0010) postoperatively accounted for the primary change in the postoperative enlargement of total EOM volume (p = 0.028). The medial rectus muscle increased 27% from the preoperative volume. The lateral rectus, superior rectus/levator complex, inferior rectus, and superior oblique muscles did not demonstrate a significant volume increase postoperatively (p = 0.23, 0.21, 0.17, 0.40, respectively). Two patients who underwent unilateral orbital decompression demonstrated EOM enlargement postoperatively in the operative orbit only. CONCLUSIONS: There is a significant increase in medial rectus muscle volume postoperatively in orbits undergoing orbital decompression for TRO despite lacking clinical evidence of disease reactivation.

Treatment of lower eyelid malposition with dermis fat grafting.

PURPOSE: To report a new technique in the repair of lower eyelid malposition using dermis fat as a posterior lamellar spacer graft. DESIGN: Retrospective, consecutive, nonrandomized interventional case series. PARTICIPANTS: Eleven patients who underwent surgical correction for symptomatic lower eyelid malposition using dermis fat as a spacer graft. METHODS: Patients with symptomatic lower eyelid malposition after blepharoplasty, trauma, craniofacial syndromes, and human immunodeficiency virus-associated lipodystrophy were treated with midfacial lifting combined with dermis fat posterior lamellar spacer grafting. MAIN OUTCOME MEASURES: Preoperative and postoperative measurements of eyelid position, margin-to-reflex distance (defined as the distance from the upper eyelid to the central corneal light reflex and the distance from the lower eyelid to the corneal light reflex), lagophthalmos, corneal staining, presence of ocular surface symptoms, and patient satisfaction. RESULTS: All patients who underwent dermis fat spacer grafting during lower eyelid malposition repair noted improvement in ocular surface symptoms and restoration of normal eyelid position. CONCLUSIONS: Dermis fat is a novel posterior lamellar spacer graft and offers numerous advantages over conventional lower eyelid spacer grafts for repair of lower eyelid malposition.

Rethinking orbital imaging establishing guidelines for interpreting orbital imaging studies and evaluating their predictive value in patients with orbital tumors.

PURPOSE: To establish guidelines for interpretation of orbital imaging by magnetic resonance imaging (MRI) and/or computed tomography (CT), and to apply these guidelines and examine their predictive value in 131 patients with biopsy-proven orbital tumors. DESIGN: Prospective evaluation of imaging studies. PARTICIPANTS: Imaging studies (CT and/or MRI) from 131 cases with biopsy-proven orbital tumors. METHODS: Guidelines for reviewing orbital imaging studies (MRI and/or CT) were established based on 5 major characteristics: (1) anatomic location, (2) bone and paranasal sinuses involvement, (3) content, (4) shape, and (5) associated features. In total, 84 features were established by an experienced orbital surgeon and a neuroradiologist. Applying these 84 features, imaging studies of 131 biopsy-proven orbital tumors were evaluated by 3 physicians. MAIN OUTCOME MEASURES: Imaging features: characteristics, sensitivity, specificity, and positive and negative predictive values in various groups of orbital tumors and kappa values. RESULTS: One hundred thirty-one cases of biopsy-proven orbital tumors were evaluated. Benign lesions were more likely to be smaller in size, round or oval in shape (29% of all benign tumors, 0% in malignant and inflammatory, P<0.001), and associated with hyperostosis (22% of all benign lesions, P<0.001). They were also more likely to be hyperdense or hypodense on CT imaging (15% and 11%, respectively; P<0.05 in comparison with inflammatory and malignant tumors). Inflammatory processes showed panorbital involvement (23% vs. 3%, and 0% in benign and malignant tumors, respectively; P<0.001). Orbital fat involvement and fat stranding were noticed only in inflammatory lesions (19% and 16%, respectively; P<0.001). None of the features occurred only in malignant tumors, but they tend to involve the anterior orbit more commonly (54% vs. 20%, and 29% in benign and malignant; P = 0.002), and were more likely to show bone erosion (31% vs. 6%, and 16% in benign and inflammatory tumors, respectively; P = 0.004) and molding around orbital structures (29% vs. 3% in benign, and 0% in inflammatory tumors, respectively; P<0.001). Features such as panorbital involvement, orbital fat, frontal sinus opacity, molding around orbital structures, perineural involvement, and fat stranding had specificity of 97% to 100%, but low sensitivity. CONCLUSIONS: Guidelines for analysis of orbital imaging studies (CT or MRI) are suggested. Based on these guidelines several imaging features showed significantly different occurrences in benign, malignant, and inflammatory processes; although this can help in differential diagnosis, tissue diagnosis may still be required.