Quantitative CMV antigenemia correlated with ophthalmoscopic screening for CMV retinitis in AIDS patients.

To assess the efficacy of the cytomegalovirus (CMV) antigen test in detecting the clinical presence of CMV retinitis. A retrospective chart review was conducted on 86 HIV positive patients who underwent dilated fundus exams for CMV retinitis. All patients had a CMV antigen assay performed within three months of their retinal exam. At a level of 45, the antigen test has a sensitivity of 96% in correctly detecting CMV retinitis and a specificity of 90.2%. The negative and positive predictive values of the antigen test were 98.2% and 80%, respectively. CMV antigen blood test provides a useful screening tool in detecting the presence or absence of CMV retinitis. An antigen level less than 45 strongly suggests the absence of retinitis.

The effects of tetanus toxin on the orbicularis oculi muscle.

PURPOSE: Tetanus toxin can cause localized neuromuscular weakness, but it also can produce systemic tetany. The action of tetanus toxin on the orbicularis muscle has not been studied in animals immunized to prevent systemic tetany. Our objective was to determine whether tetanus toxin could be used to treat orbicularis oculi muscle spasms. METHODS: We analyzed the clinical, electrophysiologic, and histopathologic effects of tetanus toxin injected into the orbicularis oculi muscle of rabbits with passive immunity to tetanus toxin. In six rabbits, the orbicularis oculi function in both eyes was assessed clinically, and the baseline orbicularis oculi muscle action potential was measured physiologically with electromyography (EMG). The rabbits then were immunized against tetanus toxin with tetanus immunoglobulin for immediate and definitive immunity. Tetanus toxin was injected into the left orbicularis oculi muscles, leaving the right eyes as controls. Ten days later, the rabbits were again assessed by clinical examination and with EMGs on both the injected side and the noninjected side. The animals were killed at 14 days, and the orbicularis muscle was removed from both sides. The injected and control tissues were examined microscopically for signs of neuromuscular denervation. RESULTS: All six rabbits showed weakness in eye closure on the side injected with tetanus toxin. In addition, four rabbits developed complete ear ptosis on the tetanus toxin injected side because of spread of the toxin to adjacent ear muscles. EMGs showed both a denervation of the orbicularis oculi muscle and a poor blink potential on the side injected with tetanus toxin. Histopathologic studies of the orbicularis oculi muscle injected with tetanus toxin showed angulation of both slow and fast types of muscle fibers compatible with neuromuscular denervation. CONCLUSIONS: Tetanus toxin can cause localized orbicularis oculi weakness, as documented clinically, physiologically, and microscopically, without producing systemic tetany in immunized rabbits. Tetanus toxin may have a potential application in the treatment of blepharospasm and hemifacial spasm.

The importance of CT scans in planning the removal of orbital-frontal lobe foreign bodies.

PURPOSE: To describe the management of foreign bodies in the orbit and frontal lobe. METHODS: Reports of two cases. RESULTS: Both patients underwent successful removal of an orbital-cerebral foreign body by anterior orbitotomy. CONCLUSION: Computed tomography was useful to confirm preoperatively that the foreign body was not adjacent to cerebral blood vessels and to monitor postoperatively for cerebral hemorrhage. A team approach is necessary in the management of orbital-frontal lobe foreign bodies.

Use of an orbital epidural catheter to control pain after orbital implant surgery.

BACKGROUND: The surgical placement of orbital implants for eviscerations, enucleations, and secondary implantations can cause severe postoperative pain that may not be relieved with high doses of narcotics. We analyzed the effectiveness of a method for postoperative pain control in orbital implant surgery using an orbital epidural pain catheter connected to a patient-controlled analgesia bupivacaine hydrochloride pump. METHODS: One hundred nineteen patients undergoing orbital hydroxyapatite implant surgery received placement of an orbital epidural catheter for the infusion of local anesthetics at the conclusion of their surgery. Patients were asked to gauge their level of comfort into the following 3 categories: total, some, or no pain relief in the first week after surgery. A separate numerical grading scale was used to further quantitate pain. Blood samples were collected in 4 patients to assess the systemic levels of bupivacaine. RESULTS: Most patients (88.2%) responded with total or some pain relief, with only 11.8% suffering severe pain. The mean numerical pain score was 2.8, within a range of 0 (no pain) to 10 (severe pain). The average plasma bupivacaine level in the 4 patients in whom this was measured was 0.38 microg/mL, which is well below the toxic level of 4.0 microg/mL. Furthermore, there were only 5 minor complications caused by the catheters, ie, 1 retrobulbar hemorrhage and 4 catheters that did not work. No permanent problems arose from any of the complications. CONCLUSIONS: The orbital epidural pain catheter is an effective means to achieve postoperative pain control after orbital implant surgery. The simple technique of insertion and management of the catheters was well tolerated in our patient population.

The treatment of punctal and canalicular stenosis in patients on systemic 5-FU.

PURPOSE: 5-FU administered systemically for cancer treatment can cause punctal and canalicular stenosis leading to symptoms of tearing. While some patients receiving 5-FU have resolution of their tearing with cessation of the drug, many patients require surgical treatment of their lacrimal outflow system. We studied the severity of punctal and canalicular stenosis in patients on 5-FU and the various treatments required to correct symptoms of tearing. METHODS: Nineteen patients (16 with colon cancer and 3 with breast cancer) who were treated with systemic 5-FU with complaints of tearing were studied retrospectively. Treatment modalities were based on punctal stenosis evaluated by slit lamp exam, and probing and irrigation of the lacrimal outflow system. RESULTS: All patients demonstrated bilateral punctal and canalicular stenosis on exam. Fifteen of the 19 patients underwent surgery with 4 declining any surgical intervention. Of those 15 patients who underwent surgery; 5 had bilateral silicone tube intubation, 3 had bilateral conjunctivodacryocystorhinostomies (CDCR), 1 had a silicone tube on one side and a CDCR on the other side, 1 had a bilateral DCR, 4 had bilateral punctal 3-snip procedures, and 1 failed bilateral silicone tube intubation and will require bilateral CDCR. CONCLUSION: This is the largest single study in the literature evaluating patients on systemic 5-FU for the sequela and treatment of tearing. Although we found varying degrees of punctal and canalicular stenosis among our 19 patients, almost all had stenosis severe enough to warrant surgical intervention with either silicone tubes or CDCR. In our study 4 of 15 patients who elected surgery (26.7%) required CDCR, because of the permanent, severe stenosis of the lacrimal outflow system. Physicians should be aware that early recognition and treatment of tearing in patients on 5-FU with silicone tubes may salvage the canalicular system and prevent the need for CDCR.

Cilia regrowth of shaven eyebrows.

OBJECTIVE: To determine if shaving eyebrows can lead to permanent brow loss. METHODS: Five patients had a single brow randomly shaven, while the unshaven brow served as a control. These patients were evaluated prospectively for brow regrowth during 6 months, and photographs were taken at each visit. Two masked observers analyzed the final photographs to determine if they could identify the side that was shaven. RESULTS: All patients had full brow regrowth by 6 months. The masked observers could not identify shaven side with any consistency. One female patient with sparser, lighter-colored brow cilia waited longer than the other patients for full brow regrowth. CONCLUSION: This small study demonstrates for the first time that full brow cilia regrowth is possible after completely shaving an eyebrow.

Orbital melanoma presenting as orbital cellulitis: a clinicopathologic report.

Most choroidal melanomas are diagnosed when the tumor is still relatively small and confined to the globe. Rarely, these tumors can escape detection and extend through the sclera. They can reach a large size and create significant orbital inflammation. The authors describe a 71-year-old man with orbital cellulitis secondary to a necrotic choroidal melanoma that invaded the orbit. This tumor had minimal intraocular involvement with a large extrascleral component. On histopathologic analysis, the lesion was best classified as a spindle B melanoma with epithelioid areas (mixed melanoma). The patient was treated with an enucleation and postoperative radiation. This report demonstrates that malignancies in the orbit can present as acute infections. Early suspicion, diagnosis, and treatment of these lesions offer the best chance for survival.

Metastatic liposarcoma to the orbit.

PURPOSE: To report a woman with blurred vision and proptosis who harbored an orbital liposarcoma that had metastasized from her abdomen. METHODS: The patient underwent an orbital biopsy, followed by postoperative intravenous corticosteroids and radiation. RESULTS: Pathology showed a dedifferentiated liposarcoma. The patient's visual acuity improved from 20/200 to 20/50 after treatment. CONCLUSIONS: Physicians should suspect the presence of this rare orbital tumor in a person with a history of liposarcoma who has proptosis. Liposarcomas usually exhibit a higher grade of malignancy with recurrence, as shown in this patient.