Accuracy of the clinical diagnosis of chalazion.

PURPOSE: A chalazion, localized lipogranulomatous inflammation of the eyelid, may simulate various eyelid lesions. This study was conducted to determine the accuracy of the clinical diagnosis of chalazion and demonstrate the importance of histopathological confirmation of the diagnosis. METHODS: Histopathological diagnoses of 1060 cases with the clinical diagnosis of chalazion, submitted to the Henry C Witelson Ophthalmic Pathology Laboratory and Registry between September 1993 and December 2001, were retrospectively evaluated. Discrepancies between clinical and histopathological diagnoses were classified. RESULTS: A total of 1033 (97.4%) of the 1060 cases were clinically diagnosed as primary and the remaining 27 (2.6%) as recurrent chalazions. Agreement was noted between clinical and histopathological diagnoses in 992 (93.6%) cases. Of the 68 (6.4%) clinically misdiagnosed cases, 15 (1.4%) were found to be malignant, two (0.2%) premalignant, and 51 (4.8%) benign conditions. Sebaceous cell carcinoma was the most commonly missed malignancy (12 cases, 1.1%) followed by basal cell carcinoma (three cases, 0.3%). Premalignant lesions, which masqueraded as chalazion, were chronic inflammation with cellular atypia and mitotic figures (two cases, 0.2%). Of these 17 cases with premalignant and malignant histopathologies, only six (35.3%) had a clinical diagnosis of recurrent chalazion, whereas the others (64.7%) were primary cases. Of the various benign conditions that were misdiagnosed as chalazion, different types of chronic inflammation (24 cases, 2.2%) were the most frequent. CONCLUSIONS: A number of different benign, premalignant, and malignant conditions may clinically masquerade as a chalazion. Delayed diagnosis and treatment of sebaceous cell carcinoma, which is the most frequently missed malignancy, may be life threatening for the patient. Therefore, all chalazion specimens, primary or recurrent, should be submitted for histopathological examination.

Marcus Gunn jaw-winking phenomenon: a new supplemental test in the preoperative evaluation.

PURPOSE: To introduce a new method for the evaluation of Marcus Gunn jaw-winking ptosis that more precisely defines the severity of blepharoptosis. METHODS: A retrospective review of 16 consecutive patients with Marcus Gunn jaw-winking ptosis presenting to our institution between 1993 to 1999 was performed. The position of the affected eyelid was observed after applying a technique of jaw immobilization and disruption of fusion with temporary occlusion of the ipsilateral side. RESULTS: In patients presenting with mild to moderate Marcus Gunn jaw-winking, the majority (62.5%) demonstrated a positive test, uncovering complete or near complete ptosis. Test results were partially positive in 3 patients (18.8%) with increased but not complete ptosis and negative in 3 patients (18.8%) with no change in eyelid position. CONCLUSIONS: Blepharoptosis associated with Marcus Gunn jaw-winking phenomenon is often more severe than found by conventional clinical evaluation. This finding may explain the frequent undercorrection and unpredictable results following levator resection. In patients exhibiting a positive jaw-winking ptosis test, disappointing outcomes with levator resection may be avoided by instead proceeding with a frontalis suspension with levator disinsertion as recommended for ptosis with severe jaw winking.

Endoscopic orbital decompression with preservation of an inferomedial bony strut: minimization of postoperative diplopia.

With the increasing sophistication and safety of endoscopic orbital decompression, the technique is seen by many as an attractive and less morbid alternative to traditional open techniques. This rationale also makes the procedure more acceptable for individuals considering decompression for cosmetic reasons. As a result, complications such as postoperative diplopia assume greater significance. Preservation of an inferomedial bony strut has been postulated to reduce the incidence of postoperative diplopia in transconjunctival, but not endoscopic, orbital decompression for dysthyroid ophthalmopathy. We present a consecutive series of 11 subjects (21 eyes) who underwent transnasal endoscopic medial and inferior decompression of the orbits bilaterally. All patient charts were reviewed in a retrospective fashion and ophthalmologic, surgical, and cosmetic data were recorded, with callback of patients with incomplete data sets. All cases were performed under general anaesthesia. Preservation of the strut was possible in 15 of 21 eyes. Visual acuity was preserved or improved in all 21 eyes. Average ocular recession based on Hertel measurements was 3.6 mm and there were no surgical complications. New-onset or worsening diplopia was noted postoperatively in 2 of 11 subjects. However, in patients where both struts were preserved, there was zero incidence of postoperative diplopia (0/6). These results indicate that preservation of an inferomedial bony strut is not only technically feasible but also does not compromise the adequacy of decompression. The results also suggest that preservation of the inferomedial bony strut during endoscopic orbital decompression can reduce the incidence of postoperative diplopia.

Homozygotes for oculopharyngeal muscular dystrophy have a severe form of the disease.

Autosomal dominant oculopharyngeal muscular dystrophy (OPMD) usually begins with ptosis or dysphagia during the fifth or sixth decade of life. We studied 7 patients with OPMD symptoms starting before the age of 36 years. All were found to be homozygotes for the dominant (GCG)9 OPMD mutation. On average, disease onset was 18 years earlier than in heterozygotes, and patients had a significantly larger number of muscle nuclei containing intranuclear inclusions (INIs) (9.4 vs 4.9%).

Short GCG expansions in the PABP2 gene cause oculopharyngeal muscular dystrophy.

Autosomal dominant oculopharyngeal muscular dystrophy (OPMD) is an adult-onset disease with a world-wide distribution. It usually presents in the sixth decade with progressive swallowing difficulties (dysphagia), eyelid drooping (ptosis) and proximal limb weakness. Unique nuclear filament inclusions in skeletal muscle fibres are its pathological hallmark. We isolated the poly(A) binding protein 2 gene (PABP2) from a 217-kb candidate interval on chromosome 14q11 (B.B. et al., manuscript submitted). A (GCG)6 repeat encoding a polyalanine tract located at the N terminus of the protein was expanded to (GCG)8-13 in the 144 OPMD families screened. More severe phenotypes were observed in compound heterozygotes for the (GCG)9 mutation and a (GCG)7 allele that is found in 2% of the population, whereas homozygosity for the (GCG)7 allele leads to autosomal recessive OPMD. Thus the (GCG)7 allele is an example of a polymorphism which can act either as a modifier of a dominant phenotype or as a recessive mutation. Pathological expansions of the polyalanine tract may cause mutated PABP2 oligomers to accumulate as filament inclusions in nuclei.

Clinically suspected primary acquired nasolacrimal duct obstruction: clinicopathologic review of 150 patients.

PURPOSE: The incidence of lacrimal sac pathology in patients with clinically suspected primary acquired nasolacrimal duct obstruction is unknown. This is an important issue when considering the potential risk of either conservative nonsurgical management or laser dacryocystorhinostomy, neither of which permits direct visualization and biopsy of the lacrimal outflow apparatus. METHODS: A total of 162 lacrimal sac biopsy specimens were obtained in 150 consecutive patients undergoing external or endonasal dacryocystorhinostomy for clinical primary acquired nasolacrimal duct obstruction from January 1992 to October 1994. RESULTS: A total of 147 patients (98%) had histopathologic findings consistent with inflammation or fibrosis of the lacrimal sac or both. In the remaining three patients, abnormalities included sarcoid granuloma (one patient), oncocytoma (one patient), and lymphoma (one patient). CONCLUSIONS: The incidence of significant pathology of the lacrimal sac in clinically suspected primary acquired nasolacrimal duct obstruction is low. However, these cases can be identified correctly only by routine biopsy of the lacrimal sac during dacryocystorhinostomy.

The anatomy of Whitnall ligament.

BACKGROUND: The current understanding of the anatomy of Whitnall ligament does not explain its functional role in eyelid movement. This anatomic study was designed to determine the exact relation of Whitnall ligament to the levator muscle and aponeurosis. METHODS: The anatomy of the eyelid was examined by surgical dissection of 20 eyelids undergoing Müllerectomy via a conjunctival approach, anatomic dissection of 20 fresh cadaver orbits, and histologic correlation in four fresh specimens. RESULTS: Whitnall ligament is a sleeve of fibrous tissue with both a superior and inferior component which join medially and laterally before inserting onto the bony orbit. CONCLUSIONS: The authors postulate that this sleeve acts as a mobile fulcrum straddling the underneath surface of the levator aponeurosis and functions to convert the anterior-posterior vector force of the levator to a superior-inferior direction during eyelid movement. This model proposes that when the levator is relaxed, Whitnall sleeve hangs down, allowing the lid to close. When the muscle contracts, the sleeve along with the levator aponeurosis is lifted superiorly in the orbit, enhancing the lifting effect of levator muscle contraction in eyelid elevation.

The effect of fluorescein volume on lacrimal outflow transit time.

The Jones primary dye test is a commonly used test of lacrimal outflow. Some clinicians, however, find it of limited practical significance because of variable outcome and relatively low sensitivity in documenting normal lacrimal excretory function. We hypothesized that an important variable affecting the transit time may be the volume of fluorescein used in the primary dye test. To accurately determine the exact time from insertion of dye into the eye to its appearance in the nose, using a rigid nasal endoscope, we directly visualized the dye as it appeared at the ostium of the nasolacrimal duct. Fifty nasolacrimal outflow systems were examined in 25 normal volunteers. The fluorescein dye transit time was determined using a single drop of fluorescein on one side and multiple drops of fluorescein on the other side. Using a single drop of fluorescein, the median dye transit time was 8 min, compared to 1.4 min using multiple drops. These results suggest that the volume of fluorescein used may be an important factor affecting variability in the outcome of the primary dye test.

Interlocking Crawford triangles in frontalis suspension.

In Crawford's pattern of frontalis suspension, two bands are passed, one nasally and the other temporally, forming two base-down triangles with their apexes attached at the brow incisions. Over time, opposing vector forces in the center of the eyelid can cause "cheese-wiring" of the bands with resultant shortening of the inferior bases of both triangles and loosening of the suspensory loops. We modified the standard pattern by interlocking the bands centrally in the lid. A mathematical model was developed that demonstrates neutralization of these opposing forces, resulting in a symmetrical and flexible redistribution of the lifting forces. In support of this mathematical model, a retrospective analysis of 42 consecutive cases using this technique revealed good aesthetic results in terms of lid height, contour, and symmetry, with no important complications from this modification.