Proptosis in a Patient With Known Graft Versus Host Disease.

A retrospective review of the medical reports of a patient who was undergoing treatment for graft versus host disease following bone marrow transplant for acute myeloid leukemia was conducted. The patient presented with persistent ocular irritation and injection. For an unclear period of time, he developed proptosis and binocular diplopia with limitation of extraocular motility insidiously. MRI revealed gross enlargement of extraocular muscles and bone marrow aspiration trephine confirmed relapse of leukemia. He then underwent chemotherapy with marked improvement of proptosis and extraocular motility. This case report highlights the importance of the eye care provider's careful assessment of patients with a history of malignancy. The presence of ocular irritation must not distract from the detection of other signs. Proptosis and extraocular motility limitation are rarely associated with graft versus host disease. The presence of these signs warrants orbital imaging to rule out recurrence of the primary malignancy.This case report highlights how proptosis and extraocular motility limitation seen in a patient with graft versus host disease may point to recurrence of the primary malignancy.

Methotrexate as an Adjuvant in Severe Thyroid Eye Disease: Does It Really Work as a Steroid-Sparing Agent?

PURPOSE: To compare the efficacy and safety of adjunctive oral methotrexate with intravenous pulsed methylprednisolone against methylprednisolone alone in the treatment of severe thyroid eye disease. METHODS: Retrospective review of clinical data of patients with severe sight-threatening thyroid eye disease with compressive optic neuropathy treated with methylprednisolone with and without methotrexate. Eye disease outcome measures (e.g., VISA inflammatory score and vision) at 0, 3, 6, 12, and 18 months were recorded. RESULTS: There were 72 subjects including 33 who had methylprednisolone alone and 39 with methylprednisolone with methotrexate. There were no statistical differences in demographics and baseline measures of disease activity or vision between the 2 treatment groups. No significant statistical differences in the cumulative dosage of methylprednisolone or occurrence of restrictive myopathy, raised intraocular pressure, proptosis, and exposure keratopathy between the groups at 0, 3, 6, 12, and 18 months were found. However, subjects who received methylprednisolone with methotrexate had better visual acuity of more than 2 lines on Snellen chart (p = 0.026) and VISA inflammatory score (p = 0.034) at 3 months, but no differences at 6, 12, and 18 months. Three patients who received methylprednisolone with methotrexate had transient worsening of liver function. No patient developed severe adverse reaction. CONCLUSIONS: The results demonstrated improved vision and disease activity at 3 months in the combination treatment group. This may suggest that the addition of methotrexate to methylprednisolone is beneficial for accelerating suppression of disease activity and hastens visual recovery. Addition of methotrexate to methylprednisolone did not reduce the requirement for steroids.

Clinical Features and Treatment Outcomes of Orbital Inflammatory Disease in Singapore: A 10-Year Clinicopathologic Review.

PURPOSE: 1) To assess the clinical profile and treatment outcomes of orbital inflammatory disease in the local population, and 2) classify patients using current histopathological criteria. METHODS: Ten-year retrospective clinicopathologic review of patients diagnosed with orbital inflammatory disease who underwent tissue biopsy from January 2001 to December 2011 at a tertiary referral centre in Singapore. Data collection included patient demographics, clinical presentation, investigations, systemic disease, histopathology review, clinical classification, medical and surgical management, response to treatment and recurrence rates. RESULTS: The study comprised 70 patients. Thirty-seven (52.9%) had nonspecific inflammation distributed as follows: lacrimal (n = 23), diffuse (n = 5), anterior (n = 5), myositic (n = 4). Thirty-three (47.1%) had specific inflammation of the following subtypes: idiopathic sclerosing inflammation (n = 9), granulomatous disorders (n = 8), transitional lesions (n = 5), vasculitis (n = 4), and others (n = 7). A total of 76.8% of patients received oral prednisolone, with a median duration of three months. Response to treatment was good in 71.9% of patients. Recurrence occurred in 22 (32.8%) patients at a mean interval of 20 months after completion of treatment, and was higher in myositic and vasculitic subtypes. There was no significant correlation between duration of treatment and recurrence. CONCLUSIONS: This study has re-emphasized the importance and utility of orbital biopsy and histopathologic typing for optimal management of orbital inflammatory disease. It has also improved the knowledge of the rate and response to treatment of its various subtypes.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society.

PURPOSE: Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED). METHODS: This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs. RESULTS: Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT. CONCLUSIONS: Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Ocular manifestations and the clinical course of carotid cavernous sinus fistulas in Asian patients.

PURPOSE: To study the clinical course with regard to both the angiographic and visual outcomes of carotid cavernous fistulas (CCFs). BACKGROUND: Carotid cavernous sinus fistulas (CCFs) are conditions which often present with ocular signs and symptoms. The clinical presentation of CCFs is varied according to the anatomy, haemodynamics and size of the CCF. CCFs causing significant symptoms or vision loss should be treated with embolization. METHODS: This is a retrospective review of the medical records of all CCF cases seen in the Singapore National Eye Centre from September 2002 to December 2011. RESULTS: 45 patients who had confirmed CCF on conventional cerebral angiography were included. Anterior draining CCFs presented with orbital congestion while posterior draining CCFs presented with pain, diplopia and cranial nerve palsies. Mild residual symptoms were still present in 85% of treated direct CCFs despite complete angiographic closure however 52% of treated dural CCFs had complete resolution of symptoms despite only half of those achieving angiographic closure. Treated and untreated dural CCFs had similar outcomes (87% versus 76% recovered or improved (p > 0.05)). Poor outcomes can result from residual diplopia or vision loss from complications of the CCF itself (e.g. compressive optic neuropathy, glaucoma, retinopathy) or complications from CCF embolization treatment (e.g. central retinal artery occlusion). CONCLUSION: Presenting symptoms and signs are related to the angiographic drainage of CCFs. Angiographic outcomes after embolization treatment may not always correlate with clinical outcomes.

Prospective audit of ptosis surgery at the Singapore National Eye Centre: two-year results.

PURPOSE: To evaluate the demographics, presentation, and surgical outcomes of patients undergoing ptosis surgery in an Asian population in a prospective manner. METHODS: A prospective ptosis audit was conducted over a 2-year period from January 2010 to December 2011 in a tertiary eye hospital in Singapore. All patients undergoing ptosis surgery by, or under the supervision of, an oculoplastic-trained consultant in the institution were included. Institutional Review Board approval was obtained for the study. RESULTS: This study comprises 302 patients, of which 236 were acquired and 66 were congenital ptosis cases. Levator repair (77.2%) was the most commonly performed procedure, followed by levator resection (13.9%) and brow suspension (8.9%). Forty-seven (10.1%) eyes had readjustment within 2 weeks, the reasons for readjustment being eyelid height undercorrection (n = 35), eyelid height overcorrection (n = 9), and unsatisfactory eyelid contour (n = 4). Postoperatively, 93.8% of patients showed an increase in marginal reflex distance-1 (MRD1), 91.3% achieved symmetry or <1 mm of asymmetry in MRD1, 98.5% had good eyelid contour, and 74.3% had symmetric eyelid crease. On a scale of 1 to 10, 83.1% of patients gave a subjective grade of 7 or better. CONCLUSIONS: This study is the first prospective ptosis surgery audit in an Asian population and takes a leading step in assessing both subjective and objective surgical outcomes in a prospective manner. With the continuation of this audit in years to come, it will allow us to generate clinical outcomes in a robust manner and allow for more reliable benchmarking with major centers elsewhere.

A survey of the histopathology of lacrimal gland lesions in a tertiary referral centre.

PURPOSE: To describe the histopathological distribution of biopsied lacrimal gland lesions in a tertiary referral centre in Singapore. METHODS: This was a retrospective chart review. Clinical records of patients who underwent lacrimal gland biopsy at a tertiary referral centre in Singapore between 2000 to 2010, were reviewed. Data collated included patient demographics, clinical presentation, association with systemic disease and histopathological diagnosis. RESULTS: Sixty-nine patients were studied. Median age of presentation was 50 years. Forty patients (58%) were female and the majority (84%, n = 29) were Chinese. The mean follow-up duration was 35.0 ± 34.5 months. 30.4% (n = 21) of the patients had bilateral disease. Chronic dacryoadenitis (46%, n = 32) was the most common histopathological diagnosis, followed by lymphoproliferative disorders (38%, n = 26) and pleomorphic adenoma (10%, n = 7). The diagnoses in four other patients included adenoid cystic carcinoma, lacrimal gland hypertrophy, lacrimal duct cyst and orbital vascular malformation. CONCLUSION: Chronic dacryoadenitis and lymphoproliferative disorders are the two commonest causes of lacrimal gland lesions in our series. Although many cases remain non-specific, about 60% have a specific inflammation that may be associated with a systemic disease. As one third of our patients with lymphoproliferative disease of the lacrimal gland had an associated systemic lymphoma, patients with such lesions should be referred for investigation of possible systemic lymphoma. The results of our study can aid in providing a more targeted approach to patient management.

Osteotome as an adjunctive instrument in endoscopic dacryocystorhinostomy.

PURPOSE: To report the novel use of the osteotome as an adjunctive instrument in Endoscopic Dacryocystorhinostomy (DCR). MATERIALS AND METHODS: A retrospective interventional case series of 15 patients, underwent endoscopic DCR at the Singapore National Eye Centre, by a single ophthalmologist and rhinologist between April 2009 and April 2011.All patients' case records were reviewed and the information recorded included: patients' demographics, level of obstruction of the lacrimal system, operative time, postoperative symptoms and complications (if any), and the length of follow-up. All patients had preoperative syringing to determine the level of obstruction, and had postoperative syringing only if there were any complaints of epiphora.All surgeries were recorded on video. The osteotome and mallet were used in all patients to augment the bone removal, and Crawford stent (MIRA®) intubation was done in all patients and left in situ for 2 months. RESULTS: A total of 15 patients were reviewed and analyzed from April 2009 to August 2010. Ages ranged from 22 to 77 years of age underwent endoscopic DCR with Crawford stent (MIRA ®) intubation. All patients had syringing before surgery and all had only nasolacrimal duct obstruction except 1 patient who had common canalicular obstruction. The surgery was carried out as described above with no intraoperative or postoperative complications in any of the patients. Duration of surgery ranged from 22 to 65 minutes with a mean time of 42.6 minutes. All patients were followed up from 2 to 11 months with resolution of epiphora in all cases. CONCLUSION: The use of the osteotome and mallet, in combination with the Kerrison rongeur and diamond drill, has been found to be useful in creating a large osteotomy in endoscopic DCR. It has allowed greater ease and speed in performing this procedure, especially for patients with thicker bone and narrower nasal cavities.

Bilateral orbital subperiosteal hemorrhage following labor.

A 27-year-old woman presented with 13 days of bilateral periorbital swelling, discomfort, and visual loss, which developed immediately after labor. She had significant blood loss requiring blood transfusion. There was bilateral proptosis, left optic neuropathy, and a superior visual hemifield defect in the left eye. MRI of the orbits showed bilateral superior subperiosteal hematomas. She underwent bilateral orbitotomy and drainage of subperiosteal hematomas. Six months later, complete resolution of proptosis with normal ocular motility and visual acuity was observed; however, there was persistence of a left relative afferent pupillary defect with superior visual field loss. This case report highlights the need for a high index of diagnostic suspicion of subperiosteal hematoma arising in a nontraumatic setting, such as in the peripartum period, and consideration for emergent surgical management of optic neuropathy.

An unusual causative agent for an orbital abscess: Granulicatella Adiacens.

We present a patient who developed an orbital abscess secondary to a retained organic (wooden) foreign body after a fall. Clinically, he had a right sub brow fistula exuding purulent discharge, four millimetres of proptosis, limitation of ocular motility in all directions of gaze, but no signs of optic neuropathy. Preoperative computed tomography and magnetic resonance imaging of the orbits was performed to localise the abscess and to facilitate surgical planning. He underwent exploration, drainage of the abscess and removal of the wooden foreign body with good postoperative recovery. Cultures isolated Ganulicatella Adiacens, a nutritionally variant streptococcus. This is an unusual causative organism and to our knowledge, this is the first reported case of a posttraumatic orbital abscess associated with Granulicatella Adiacens. Clinical suspicion, isolation of the organism and appropriate microbial treatment requires a multidisciplinary approach, with input from the ophthalmologist, microbiologist and infectious disease team. This will ensure a good outcome in patient management.

Neuroendocrine tumors of the orbit--clinicopathological findings in 3 more cases of this rare entity and review of the literature.

INTRODUCTION: Neuroendocrine orbital tumors are rare occurrences. They are poorly characterized histologically and a spectrum of different cell types exists. This short case series studies the various tumor morphologies as well as the patients' clinical profiles. METHODS AND MATERIALS: Patients treated and followed up at the Singapore National Eye Centre over a period of 8 years from 1(st) January 2002 to 31(st) December 2009 were identified from the orbital tumor board results. The case notes of patients with the diagnosis of neuroendocrine tumors were analysed, and a review of the literature performed. RESULTS: Three patients are described in this series. The history, clinical examination findings, imaging findings as well as tumor histology were described. The mean age was 63 years, and 2 patients were male. All presented with proptosis. Only one patient had systemic symptoms on presentation. All patients had surgical excision of the tumor and two had adjuvant radiotherapy of the orbit. Median follow-up period was 3.5 years. DISCUSSION: Patients with a biopsy-proven diagnosis of orbital neuroendocrine tumors should be monitored even when systemic examination fails to identify peripheral disease. Such examination should always include a full endoscopic gastrointestinal review.

Visual outcomes in patients with paranasal mucoceles.

PURPOSE: To describe the ophthalmic complications and visual outcome of patients with paranasal mucoceles. METHODS: This is a retrospective case series of patients with a diagnosis of paranasal mucocele. Their medical records were examined with particular emphasis on the location of the paranasal mucoceles, presence of inflammation (mucocele vs. pyelocele), presence of optic neuropathy, and final visual outcome. RESULTS: Ten patients with an average age of 57.6 years (range, 30-71 years) were studied. Seven mucoceles were in the frontal or fronto-ethmoidal sinuses, one was in the sphenoidal sinus, one was within an Onodi cell, and one was in the maxillary sinus. Four patients developed optic neuropathy, of which 2 cases were related to fronto-ethmoidal mucoceles. Four patients had pyeloceles. Two of these 4 patients had resultant loss of light perception: one case was associated with a fronto-ethmoid sinus and the other with an Onodi cell). CONCLUSIONS: Our series highlights the greater risk of optic neuropathy and poor visual outcome with sphenoid sinus and Onodi cell mucoceles because of their proximity to the optic nerve. However, fronto-ethmoidal mucoceles are not benign and may compromise vision, especially if a posterior ethmoid component is present, or if treatment is delayed and secondary infection has ensued to form a pyelocele. Management of paranasal mucoceles should be prompt, particularly when signs of inflammation are present.

Stereotaxy for surgical navigation in orbital surgery.

PURPOSE: Image guidance has been used in neurosurgery with great success. The authors illustrate the use of stereotaxy and neuronavigation in the surgical management of a cranio-orbital tumor and for orbital decompresson in thyroid orbitopathy. METHODS: Stereotactic image guidance was used in the surgical management of 2 patients, one with a large left sphenoid wing meningioma causing proptosis and visual loss from orbital extension, and the other with disfiguring proptosis due to thyroid eye disease. Virtual reality simulation was used preoperatively in the first patient to visualize surgical corridors of approach to the tumor. RESULTS: The patients underwent successful orbital surgery aided by intraoperative neuronavigation. The sphenoidal wing meningioma was removed completely with no damage to adjacent orbital and intracranial tissues, and orbital decompression was successfully performed with good cosmetic improvement. CONCLUSION: Image-guided neuronavigation in our cases allowed for safe and precise surgery, with avoidance of complications.

Nasolabial fold angle measurement using anterior segment optical coherence tomography in normal subjects.

PURPOSE: The human nasolabial fold angle (NFA) has been measured using MRI and photogrammetry and has been shown to decrease with age. The authors aimed to evaluate a novel method using optical coherence tomography to measure the NFA. METHODS: In this cross-sectional observational series, the authors used anterior segment optical coherence tomography (ASOCT) to image the NFA of both cheeks of 126 subjects aged 21 to 79 years. A dental vinylpolysiloxane custom-designed mould was used as a chin rest. The mean of 3 scans on each side was calculated and analysis of variance, multiple comparisons, and multiple linear regression were carried out using SPSS 11.0. RESULTS: Sixty-one subject (48.4%) were men and 65 (51.6%) were women. Mean age was 50.6 +/- 16.8 years (range, 21-79 years). The ASOCT successfully imaged the NFA in all subjects. Mean right and left NFA were 144.4 degrees +/- 17.1 degrees and 145.4 degrees +/- 17.7 degrees. The NFA were dissimilar between the 6 age categories by decade (p < 0.001). Age was the significant predictor of NFA, accounting for 55% of NFA variation. Every year accounted for a decrease of 0.78 degrees (p < 0.001) and 0.80 degrees (p < 0.001) for the right and left cheeks, respectively. Male sex resulted in an increase in NFA of 5.4 degrees (p = 0.007) and 4.0 degrees (p = 0.06) in the right and left cheeks, respectively. CONCLUSIONS: The NFA decreases with age and increases with male sex and can be measured with ASOCT accurately and easily.

Onodi sinusitis presenting with orbital apex syndrome.

This article reports the unusual presentation of a patient with an intraconal abscess secondary to sinusitis in an onodi cell in a healthy 63 year old Chinese female. She presented with limited extraocular movements, decreased corneal sensation, rapid drop in visual acuity and signs of optic neuropathy, in the absence of any inflammatory signs in the right eye. MRI scans showed a well-encapsulated mass in the posterior two thirds of the orbit, with the presence of an onodi cell on the right side. She underwent an extended lateral orbitotomy, which revealed frank pus that was positive for Staphylococcus aureus. She was treated with intravenous antibiotics with complete resolution of her presenting signs.

Orbital cellulitis in children-medical treatment versus surgical management.

INTRODUCTION: Ophthalmologists differ in their threshold for surgical management in paediatric patients with orbital cellulitis. We studied the management choices and outcome of children admitted with this disorder. MATERIAL AND METHODS: A retrospective review was performed on patients with orbital cellulitis admitted between January 2001 and December 2004 to a tertiary paediatric referral centre in Singapore. The patients were studied for age, associated systemic disease, medical treatment, drainage procedure undertaken, organism isolated and outcome. Statistical methods were applied for comparing medical treatment with surgical treatment with respect to recovery time, recurrence, and time between the presentation of patient and initiation of treatment. RESULTS: Twenty patients were studied. Average age was 5.5 years. 5/20 (25%) had a preceding history of upper respiratory tract infection. From CT findings, we came to know that 3/20 (15%) were due to isolated ethmoiditis, 5/20 (25%) had obstruction of the osteomeatal complex of the paranasal sinuses, 2/10 (10%) had intracranial abscesses due to frontal sinusitis. 4/20 (20%) had all 4 ipsilateral paranasal sinuses infected. 2/20 (10%) had preseptal cellulitis with posterior extension into the orbit. 2/20 (10%) had orbital cellulitis related to dacryoadenitis and 2/20 (10%) had pansinusitis with orbital soft tissue stranding. 13/20 (65%) had orbital and /or endoscopic drainage. The remainder of the patients had good immediate response to sole medical treatment and did not require surgery. The most commonly isolated organism was Staphylococcus aureus 5/20 (25%). All patients recovered within a mean of 9.6 days with no complications or functional deficit. CONCLUSIONS: Paediatric orbital cellulitis can be treated conservatively or with surgical drainage. Indications for surgery include pansinusitis, large abscesses with significant mass effect, concurrent intracranial involvement, poor response to initial medical treatment and the presence of an orbital abscess and gas. Sole medical treatment worked well in children with no orbital abscess, small or medial abscesses as they tend to have a single organism infection. This is also of particular significance in young children below the age of one where endoscopic surgery can be technically difficult. Intracranial involvement occurred in association with frontal sinusitis and affected patients had the longest duration of hospitalization.

The tear cytokine profile in patients with active Graves' orbitopathy.

PURPOSE: The primary aim of this study is to isolate cytokines specific for active Graves' orbitopathy (GO) in the tears of affected patients. The secondary aim is to identify other cytokines of interest and to look at the profile of their levels over time. METHODS: This is a prospective pilot study conducted at the Singapore National Eye Centre. A total of 10 patients with active GO and 10 patients from each of 3 control groups were recruited. The 3 control groups were the following: age-matched normal female patients, patients with GO who were clinically inactive and patients with bilateral viral conjunctivitis. Tears from patients from the control groups were collected on a single visit. For patients with active GO, tears were collected on presentation, at 6 months, 12 months and 18 months. RESULTS: Of all the cytokines examined, only IL-7 yielded a difference when the concentration in patients with active GO was compared with concentrations in all the control groups. This difference was most significant at the 18-month follow-up visit. CONCLUSIONS: Low concentrations of IL-7 in tears exhibit specificity for active GO in patients nearly 2 years from the clinical onset of activity. Although using IL-7 in tears as a biomarker for disease activity may be limited due to its late manifestation, targeting immune restitution using IL-7 may have disease modifying effects.

Orbital metastatic tumour as initial manifestation of asymptomatic gastric adenocarcinoma.

INTRODUCTION: Metastatic orbital tumour from gastric cancer is rare. Patients with metastatic disease may present initially to the ophthalmologist with symptoms from metastases instead of from the primary cancer. CLINICAL PICTURE: We report a case, with clinicopathological correlation, of metastatic gastric adenocarcinoma presenting first in the orbit with diplopia. Computed tomography and magnetic resonance imaging of the orbit showed a well-defined enhancing right intraconal tumour. TREATMENT AND RESULTS: Excisional biopsy was performed and histopathology confirmed a metastatic adenocarcinoma. Focused gastrointestinal screening revealed an otherwise asymptomatic Stage IV gastric adenocarcinoma. Chemotherapy was initiated with good tumour response. CONCLUSION: Early biopsy of unusual orbital tumours is critical as orbital metastases may be the initial manifestation of an asymptomatic primary. Histopathological diagnosis can aid localisation of the primary tumour and allow prompt treatment to be instituted.

Mantle cell lymphoma in the ocular adnexal region.

PURPOSE: To study the clinicopathologic features of mantle cell lymphoma (MCL) in the ocular adnexal region. DESIGN: Retrospective review. METHODS: The slides of 23 suspect patients were reevaluated with a panel of monoclonal antibodies, including anti-CD20, cyclin-D1, CD5, CD3, and p53 immunostains. Patients confirmed to have MCL were examined retrospectively on the basis of chart review. RESULTS: Ten patients with periocular MCL were included in the study on the basis of characteristic histopathologic features and coexpression of nuclear cyclin-D1. This included 1 female and 9 male patients, with an age range of 32 to 84 years (median, 73.5 years). Median follow-up was 20 months (range, 5-172 months). Six of the 10 patients died, all of lymphoma. The orbit (90%) was most commonly involved followed by the lacrimal gland (50%) and lid (50%), with 90% of cases having lymphoma present at 2 or more periocular sites. Most had a primary periocular presentation (80%) that was associated with stage III/IV disease (80%), including atypical cells in the peripheral blood smear (60%) and bone marrow involvement (70%) at presentation. Three cases were CD5-negative, and 2 other cases showed composite histologic findings (MCL and follicular lymphoma and MCL and a plasma cell neoplasm). Fluorescent in situ hybridization performed in these 2 cases demonstrated t(11;14) in the MCL component. Actuarial survivals were median progression-free (PFS) survival, 12 months; median overall survival (OS), 57 months; 5-year PFS, 0; 5-year OS, 39%. CONCLUSIONS: Mantle cell lymphoma presenting in the ocular adnexal region has a male predominance and tends to affect an elderly age group, as is typical of MCL involving nodal sites. A higher frequency of these tumors fail to co-express CD5, and composite lymphomas were observed in 20% of patients. Mantle cell lymphoma presenting in the ocular adnexal region is associated with advanced-stage disease and short PFS but an OS similar to MCL at other sites.

"Walk the Rim, Feel the Bone" Technique in Superior Sulcus Filling.

Superior sulcus filler injection is a nonsurgical method to rejuvenate the upper face. Blindness and stroke are devastating complications of facial filler injection. This study describes an injection technique that minimizes the risk of blindness and includes a case study demonstrating the cosmetic benefits of this procedure. To avoid retrograde injection of filler embolus into the ophthalmic artery, we advocate a "'walk the rim, feel the bone" approach. Small boluses of hyaluronic acid filler are given in preperiosteal plane, avoiding the superior orbital foramen.