A case of mistaken identity: the role of lacrimal gland pleomorphic adenoma tissue diagnosis.

PURPOSE: Lacrimal gland lesions have diverse pathologies. Bone remodelling on imaging may suggest a benign lacrimal gland pleomorphic adenoma (LGPA) rather than a malignant process. METHODS: The authors report a case of malignant pleomorphic adenocarcinoma, which was misdiagnosed clinico-radiologically as a benign LGPA. Lesions with bone remodelling on CT imaging were subsequently analysed amongst a cohort of 31 lacrimal gland lesions from a single tertiary centre. RESULTS: 31 lacrimal gland lesions biopsied over a ten-year period featured bone remodeling on CT scan, typical of LGPA. Three diagnoses were of pleomorphic adenocarcinoma. Two of these cases presented classically with unilateral painful eyelid swelling and bone destruction or bone erosion on CT scan. Seven patients (23%) in this ten-year period had bone remodeling on CT scan, typical of LGPA. Of these seven cases, three were LGPA, but the other four cases were a mixture of other diagnoses. CONCLUSION: Clinical and radiological suspicion of LGPA may be inaccurate and requires prompt histological diagnosis to facilitate appropriate further treatment and prognosis.

The lower lid diamond: a simple entropion repair to correct both horizontal and lower-lid retractor laxity.

PURPOSE: To describe a simple technique for involutional entropion correction and to present the findings of a pilot study. METHODS: Consecutive case series of 42 procedures. Patients presenting with involutional entropion in the absence of lateral canthal tendon laxity (lateral canthus could be distracted 1 cm or more medially) underwent a modified full-thickness eyelid shortening combined with retractor plication. Main outcome measures were correction of entropion and cosmesis of the surgical site at final follow up. RESULTS: At final follow up, 92% of patients had a satisfactory eyelid position with no recurrence of entropion and a cosmetically satisfactory scar. CONCLUSIONS: This is a useful technique with a higher success rate than everting sutures and is particularly suitable for patients for whom rapid surgery is needed or a lateral canthotomy is best avoided.

Radiologically manifested accessory extraocular muscles in thyroid eye disease.

The authors describe 3 patients with Graves orbitopathy who all have accessory orbital structures on orbital imaging. These structures are isodense on CT and isointense on MRI to the extraocular muscles and have a similar anatomical appearance to accessory extraocular muscles previously described in the literature. The authors propose that Graves orbitopathy involves these accessory muscles and makes them visible on imaging.

Eyelid contracture may indicate recurrent basal cell carcinoma, even after Mohs' micrographic surgery.

Mohs' micrographic surgery (MMS) is an effective means of margin control in the management of periocular basal cell carcinomas (BCC). We describe three cases of recurrent BCC that presented with progressive eyelid contracture after MMS. They illustrate high-risk factors for recurrence, namely large tumor size, medial canthal location, previous treatment, and aggressive histological features. Careful long-term surveillance with serial photography may identify early eyelid contracture and thus assist in the detection of recurrent BCC after MMS and improve patient outcome.

Confident complete excision of lid-margin BCCs using a marginal strip: an alternative to Mohs' surgery.

AIMS: To report a new technique of tissue preparation, using a marginal strip, after the excision of eyelid basal cell carcinomas (BCCs) and to report the long-term results of BCCs excised using this technique. METHOD: After the excision of eyelid BCC with a safety margin of 4 mm, a 1 mm strip was excised along the whole perimeter from the margin of the freshly excised specimen. This marginal strip had intact conjunctival mucosa along one edge and skin along the other. The marginal strip and the central tumour mass were then fixed immediately in formal saline and subjected to conventional histopathology. RESULTS: Of the 61 patients who completed a 5 years follow-up, the results of 28 eye-lid BCCs that were within 4 mm of the lid margin are reported. The marginal strip was clear in 22 specimens and had the presence of residual tumour in its margin in 6 specimens. These six 6 cases were further managed by observation (n = 2), by further surgical excision using marginal strip (n = 2) and by Mohs' surgery (n = 2). CONCLUSION: Marginal strip examines the entire resection margins analogous to Mohs' technique and we recommend its use in lid margin where tarsus is present throughout the specimen and >4 mm from the lid margin.

Adrenal suppression and failure to thrive after steroid injections for periocular hemangioma.

PURPOSE: To evaluate the effects of steroid injections for periocular capillary hemangioma on adrenal function and body composition. DESIGN: Noncomparative, interventional case series. PARTICIPANTS: Four patients with periocular hemangioma. METHODS: Four white female infants with sight-threatening periocular hemangiomata received a combination of steroid injections of triamcinolone and betamethasone. In the first 2 cases, injections were perilesional and in the other 2, intralesional. MAIN OUTCOME MEASURES: The infants were monitored by serial measurements of basal serum cortisol concentrations, responses to the Synacthen stimulation test, measurement of growth and of weight gain, and, in one case, more detailed anthropometric measures of body composition. RESULTS: Prolonged suppression of circulating serum cortisol concentrations and cortisol responses to the Synacthen stimulation test were noted in 3 cases, and marked failure to thrive was noted in all 4 cases. CONCLUSIONS: Adrenal suppression after steroid injection for periocular capillary hemangioma is a potentially life-threatening complication. Failure to thrive is also a frequent side effect of treatment. Ophthalmologists should undertake the above treatment in consultation with a pediatric endocrinologist.

Multi-center study on the characteristics and treatment strategies of patients with Graves' orbitopathy: the first European Group on Graves' Orbitopathy experience.

UNLABELLED: To improve management of patients with Graves' orbitopathy, a multi-center collaborative approach is necessary in order to have large enough sample sizes for meaningful randomized clinical trials. This is hampered by a lack of consensus on how to investigate the eye condition. The European Group on Graves' Orbitopathy aims to overcome this and has designed a preliminary case record form (CRF) to assess Graves' orbitopathy patients. This form was used in this first multi-center study. AIM: To investigate patient characteristics and treatment strategies in 152 new consecutively referred patients with thyroid eye disease seen in nine large European referral centers. METHODS: Newly referred patients with Graves' orbitopathy were included who were seen between September and December 2000. Demographic data and a complete ophthalmological assessment were recorded. RESULTS: One-hundred and fifty-two patients (77% females) were included. Diabetes was present in 9%, and glaucoma or cataract in 14% of patients. Forty percent were current smokers, 9% also had dermopathy, and only 33% reported a positive family history of thyroid disease. Mild eye disease was seen in 40%, moderately severe eye disease was seen in 33% and severe eye disease was seen in 28% of patients. Soft tissue involvement was the most frequent abnormality (seen in 75%), proptosis > or =21 mm was found in 63%, eye motility dysfunction in 49%, keratopathy in 16% and optic nerve involvement was found in 21% of patients. According to the clinical impression, 60% had active eye disease. Immunosuppressive treatment was planned more frequently in active patients (57/86; 66%) than in inactive patients (5/57, 9%; Chi-square 46.16; P<0.02). There were no important differences among the eight centers regarding the severity and the activity of their patients. CONCLUSIONS: In view of the large number of patients recruited in only 4 months, multi-center studies in the eight EUGOGO centers appear to be feasible.

Orbital cellulitis with gas.

Orbital cellulitis due to presumed gas-producing organisms has been associated with poor visual prognosis. We report successful visual recovery in a 14-year-old boy with orbital cellulitis and gas in the orbit on CT scan. The patient was treated with intravenous antibiotics and prompt orbital decompression. Pus from the sinus aspirate and orbital drain grew H. influenzae and Gram-negative bacilli. Repeat orbital surgery with drainage of residual abscess was performed and the patient made a complete recovery.