Steroid-induced ptosis: case studies and histopathologic analysis.

PURPOSE: The purpose of this study was to review patients who developed ptosis after subtenon's steroid injection and to study the mechanism of steroid-induced ptosis in an animal model. METHODS: Part 1. Twenty-two patients with uveitis who had received posterior subtenon's triamcinolone acetonide injections were retrospectively reviewed. Demographics, type of uveitis, type and number of surgeries, pre and postoperative marginal reflex distance (MRD1), and clinical outcomes were evaluated. Part 2. Study of rabbit levator muscle and aponeurosis histopathology after subtenon's triamcinolone injection was performed. RESULTS: Part 1. The average age was 44.6 years (range: 14-85 years) with a mean follow-up of 14 months. The most common causes of uveitis included uveitis after cataract extraction (five), pars planitis (three), multifocal choroiditis (three), and juvenile rheumatoid arthritis (three). The average time to documented onset of ptosis was 13.9 months (range: 0-49 months). In patients who received only one steroid injection, the average time to ptosis recorded was 2.7 months (range: 0-6 months). Seventeen patients underwent ptosis repair. Part 2. No ptosis was noted in the experimental and control groups. Histopathologic analysis of levator tissues revealed no significant difference in atrophy or degree of inflammation between experimental and control groups. CONCLUSIONS: Ptosis following subtenon's steroid injection ranged from mild to moderate and occurred a few months after steroid injection. Prior studies of muscles and periocular tissues exposed to corticosteroids demonstrated degenerative muscle changes; our studies revealed no histopathologic changes in the levator muscle or aponeurosis.

Predictive value of the initial quantified relative afferent pupillary defect in 19 consecutive patients with traumatic optic neuropathy.

PURPOSE: To study the predictive value of the initial quantified relative afferent pupillary defect (RAPD) in patients with indirect traumatic neuropathy as it relates to final visual outcome. METHODS: The RAPD was measured and quantified by neutral density filters in patients with unilateral indirect traumatic neuropathy. All patients were treated with megadose methylprednisolone by of the protocol established by the Second National Acute Spinal Cord Injury Study. Patients were followed twice daily during treatment and then at 3-month intervals. RESULTS: Nineteen patients were enrolled over a 23-month period. Patients ranged in age from 12 to 78 years old; 18 of the 19 patients were male. No patient with an RAPD of 2.1 log units or greater had visual recovery to better than hand motion vision. The 7 patients with an initial RAPD of less than 2.1 log units showed improvement in their RAPD and were found to have vision of 20/30 or better during the follow-up period. CONCLUSIONS: In patients treated with megadose methylprednisolone with an initial RAPD of less than 2.1 log units, visual acuity improved to 20/30 or better; however, patients with an initial RAPD of 2.1 or greater showed little visual improvement. The initial quantified RAPD appears to have a predictive value related to final visual outcome.

Adenocarcinoma of the esophagus presenting as orbital cellulitis.

A 56-year-old man was seen with signs and symptoms consistent with orbital cellulitis. Computed tomographic scan showed a localized bony defect in the sphenoid wing, on which a biopsy was performed through a lateral orbitotomy. Pathologic examination of the surgical specimen revealed mucinous adenocarcinoma, and metastatic workup revealed an extensive lower esophageal malignant neoplasm. Arch Ophthalmol. 2000;118:986-988

Clinical factors influencing periocular surgical defects after Mohs micrographic surgery.

PURPOSE: To determine if the surgical defect after excision of periocular skin cancers can be predicted preoperatively. METHODS: Review of medical records of patients who underwent excision of periocular skin cancers between 1990 and 1995. RESULTS: Two hundred sixty-four patients (157 men, 107 women) with a total of 281 malignant tumors were treated. Basal cell carcinoma accounted for 92.2% of the tumors, whereas squamous cell carcinoma constituted 6.4% of lesions. The lower eyelid and medial canthus were the most frequent sites of involvement. Data analysis was conducted on tumor size, cell type, location, and the Mohs stages and sections that were required for cure. Morpheaform basal cell carcinomas required the most Mohs stages and sections and resulted in the largest excisional defects when compared with clinical tumor dimensions. The lateral canthus had the fewest tumors, but lesions in this area resulted in the largest excisional defects (mean, 9.5 cm2) when compared with lesions of the medial eyelid (p = 0.35). The average size of the defect after Mohs excision of basal cell carcinoma was 4.2 to 4.6 times the original clinical tumor size. For morpheaform basal cell carcinoma, however, the average excisional defect was 6.1 times larger. Conversely, the average defect after excision of squamous cell carcinoma was only 2.6 times as large as the original clinical tumor size. CONCLUSIONS: These data are useful in predicting the size of a defect after Mohs excision of periocular skin cancer, based on the original clinical tumor size.

Ophthalmic manifestations of fibrous dysplasia: a disease of children and adults.

OBJECTIVE: To determine whether adults constitute a significant proportion of patients presenting with ophthalmic complications of fibrous dysplasia. DESIGN: A retrospective case series. PARTICIPANTS: Twenty patients with biopsy-proven fibrous dysplasia participated. MAIN OUTCOME MEASURES: Patient demographics, major signs and symptoms, occurrence of visual loss, pattern of bone involvement, and radiographic appearance of fibrous dysplasia were studied. RESULTS: In contrast to observations made in the past, the authors found that adults constitute a significant proportion of patients suffering from the ophthalmic complications of fibrous dysplasia. Of 20 patients, 9 were younger than 18 years of age (children) and 11 were 18 years of age or older (adults) at the time of presentation. Changes in facial contour and symmetry were the most common presenting signs and symptoms. Five patients, four of whom were adults, presented because of acute visual loss. Most patients had monostotic lesions that crossed suture lines to involve multiple craniofacial bones. On computed tomographic scan, most fibrous dysplasia lesions had a characteristic, pagetoid appearance, with alternating areas of radiolucency and radiodensity. CONCLUSIONS: Because fibrous dysplasia of the orbital bones can be a cause of significant dysfunction and disfigurement, as well as a treatable cause of blindness in both children and adults, the diagnosis of fibrous dysplasia should not be ruled out based solely on the age of the patient. The characteristic radiologic appearance of this disease allows one to differentiate fibrous dysplasia from other tumors associated with bony expansion or density changes, specifically meningioma.

Management of displaced lateral orbital wall fractures associated with visual and ocular motility disturbances.

Impacted fractures of the lateral orbital wall are a type of orbital blow-in fracture that may be accompanied by decreased visual acuity and ocular motility limitations. Eleven patients who suffered this injury triad were retrospectively reviewed to determine the nature of the ophthalmologic injuries and the effect of fracture reduction on recovery of ophthalmologic functions. Two patients with decreased visual acuity owing to trauma to the globe recovered to subjective pretrauma levels following surgery. Nine patients were thought to have a traumatic optic neuropathy with varying degrees of visual loss. Patients with an injury to the intraorbital portion of the optic nerve and a presurgical visual acuity of 20/400 or better recovered to subjective pretrauma levels. Those with visual acuity of less than 20/400 or an injury to the intracanalicular portion of the nerve had responses ranging from no improvement to objective improvement with large field defects. Ocular motility improved in all patients, many in the immediate postsurgical period consistent with removal of a mechanical restriction. No patients had worsening of ophthalmologic deficits as a result of manipulation of fracture fragments. Our experience suggests that early surgical intervention facilitates recovery of vision and eye movement. The traumatic optic neuropathy that accompanies this fracture is distinct from the indirect type of optic nerve injury that may respond to steroids, and the ophthalmoplegia is distinct from the usual traumatic superior orbital fissure syndrome that resolves spontaneously. An understanding of the impacted lateral orbital wall fracture and its ophthalmologic implications is essential for any surgeon who desires to manage craniomaxillofacial injuries.

Periocular necrotizing fasciitis: a review of five cases.

OBJECTIVE: The purpose of the study is to display a spectrum of clinical presentations of periocular necrotizing fasciitis caused by group A streptococci and to discuss recent trends and treatment of this disease. DESIGN AND INTERVENTION: A case series of five patients (four female and one male) was seen between July 1990 and January 1995 in four university centers. All had clinical evidence of periocular necrotizing fasciitis and grew group A streptococci on wound cultures or had serologic evidence of streptococcal infection. Details of patient presentation, treatment, and outcome are examined. RESULTS: The five patients showed a spectrum of clinical severity from a necrotizing infection confined to the eyelid to a potentially fatal, severe shock-like syndrome characterized by sepsis and multiorgan system failure. A history of trauma often was absent. Patients were treated successfully by a combination of appropriate antibiotics and surgical debridement. CONCLUSIONS: Group A streptococci can cause severe necrotizing infections of the eyelids. Early recognition and prompt treatment can be essential to these patients' survival.

Pseudomonas dacryoadenitis secondary to a lacrimal gland ductule stone.

Infectious dacryoadenitis is a rare condition. A case of Pseudomonas dacryoadenitis has not been reported previously. We treated a patient with Pseudomonas dacryoadenitis secondary to obstruction from a lacrimal gland ductule stone. Histologically, the calculus contained hairs.

Unusual skin depigmentation following eyelid cryosurgery.

A 71-year-old African-American man was treated with cryosurgery of the left lower lid for trichiasis. Dramatic depigmentation of the lid skin followed, including substantial pigment loss on the untreated upper lid. Pigmentation returned to nearly normal over a 9-year period. Depigmentation of the skin following cryosurgery is a well-known complication. The clinical course of the depigmentation, however, is not well demonstrated in the literature. This case documents, with clinical photographs, the spontaneous return to nearly normal pigmentation 9 years following the cryosurgery. In addition, the extensive depigmentation seen in this patient cannot be explained by cryoinjury alone. We speculate that the depigmentation was due, in part, to segmental vitiligo initiated at the site treated with cryosurgery.

Bilateral enophthalmos associated with hydrocephalus and ventriculoperitoneal shunting.

BACKGROUND: Progressive bilateral enophthalmos in the absence of previous trauma is rare. METHODS: Three patients with progressive bilateral severe enophthalmos whose only significant medical history was that of congenital hydrocephalus were treated by ventriculoperitoneal shunt placement. RESULTS: The patients demonstrated severe bilateral enophthalmos with poor eyelid apposition to the globes resulting in superficial keratopathy. Orbital computed tomographic scans confirmed the severe enophthalmos, with apparent reduced orbital fat volume. Orbital bony anatomy appeared normal. CONCLUSIONS: Bilateral progressive enophthalmos may be associated with hydrocephalus and ventriculoperitoneal shunting. The causal mechanism remains speculative.

Surgical excision of periorbital capillary hemangiomas.

BACKGROUND: Periorbital capillary hemangiomas of childhood can produce ptosis, strabismus, and anisometropia, resulting in amblyopia. Traditional therapy with either systemic or local corticosteroids occasionally yields incomplete resolution of these lesions and may be associated with numerous adverse complications. The authors report their experience performing surgical resection of periorbital capillary hemangiomas. METHODS: Twelve children with periorbital capillary hemangiomas were treated surgically. Six of these children had previously failed to adequately respond to steroid injections and six were primarily treated with surgical resection. All lesions were believed to be localized and did not appear to be infiltrative on preoperative computed tomographic scans. RESULTS: All lesions were completely resected, except for two in which there was a small area of residual hemangioma surrounding the lacrimal drainage system that was left intact. Controlled intraoperative hemorrhage in two patients required intraoperative directed-donor blood transfusion. Perioperatively, in one patient a wound dehiscence developed, which required minor repair. This same patient elected to have surgical scar revision postoperatively. The patients have been followed up to 5 years. All did well with improved cosmesis, and they have good lid function. No recurrences have been noted. CONCLUSION: Surgical resection of pediatric capillary hemangiomas should be considered a treatment option in those that fail to respond to corticosteroids and/or are isolated and noninfiltrative in nature.

Orbital dermoid cysts located within the lateral rectus muscle.

BACKGROUND: Two patients, a 13-year-old girl and a 31-year-old man, had an orbital dermoid tumor located in the lateral rectus muscle. This unusual location of dermoid tumors has not been reported previously. METHODS: Computed tomography and magnetic resonance imaging showed a cystic mass within the belly of the lateral rectus in each patient. Surgical excision through a lateral orbitotomy showed a well-circumscribed mass surrounded by lateral rectus fibers. No periorbital attachment was noted. RESULTS: Results of histopathologic evaluations showed a dermoid cyst. Postoperatively, the diplopia and proptosis resolved. In one patient, an unusual subconjunctival deposition of fat droplets was seen. CONCLUSION: The findings in patients demonstrate an unusual presentation of dermoid cysts and make an addition to the differential diagnosis of enlarged extraocular muscles.

Medial canthoplasty with microplate fixation.

Six patients with malpositioned or surgically excised medial canthal tendons underwent repair with titanium microplate, and two patients underwent repair with titanium miniplate fixation. The T-shaped rigid fixation plates were chosen for medial canthal reconstruction to allow for stabilization of the plate along the anterior lacrimal crest and extension of the plate over the posterior lacrimal crest. The medial canthal tissue was reattached to the titanium plate with 3.0 polypropylene (Prolene) suture. This technique appears to be safer, faster, and, in many cases, more effective than traditional techniques for reconstruction of the medial canthus after tendon avulsion or loss from excision of cutaneous carcinoma.

Complications associated with alloplastic implants used in orbital fracture repair.

BACKGROUND: The treatment of orbital wall fractures involves observation and/or surgical reduction with repositioning of herniated orbital tissues. To prevent reherniation of tissue and development of enophthalmos, the orbital floor or wall defect is commonly covered with an alloplastic implant. Complications associated with these implants are infrequent and generally appear as isolated case reports. METHODS: The authors reviewed the files of four consultative oculoplastic surgeons and searched for individuals with complications secondary to their alloplastic implants used during orbital fracture repair. FINDINGS: Seventeen patients were identified with a variety of complications related to their alloplastic implant. CONCLUSION: Although these implants are relatively inert and develop a fibrous capsule walling them off from the surrounding orbit, they remain foreign bodies and are thus subject to possible complications at any time. The authors review the spectrum of complications occurring with various alloplastic implants.

Phakomatous choristoma of the orbit: a case report.

We report the case of a 3-month-old infant with a rare phakomatous choristoma of the orbit. This lesion is believed to be a congenital neoplasm of lenticular anlage. The clinical, radiological, and histopathological findings are presented.

Clinical characteristics associated with orbital invasion of cutaneous basal cell and squamous cell tumors of the eyelid.

Over a six-year period, between 1984 and 1990, 622 patients with basal cell and squamous cell carcinoma of the eyelids were examined at our institution. Thirteen patients had orbital invasion at initial examination. The average age of patients at orbital invasion was 75.8 years. Ten patients were men, eight of whom had basal cell carcinoma and two of whom had squamous cell carcinoma. Most patients had an orbital mass and incomitant strabismus at initial examination. Invasive basal cell carcinoma developed in 11 patients, and squamous cell carcinoma developed in two patients. Ten patients were treated for cutaneous carcinoma at the site of invasion before examination at our institution. The average duration between onset of a cutaneous lesion and our examination for orbital invasion was 9.8 years for basal cell carcinoma and one year for squamous cell carcinoma. Radiologic and histopathologic features were reviewed. The clinical characteristics of these patients were reviewed and orbital exenteration was recommended to all 13 patients. Nine patients underwent exenteration and four refused the operation.