Spontaneous superior ophthalmic vein thrombosis: a rare entity with potentially devastating consequences.

PURPOSE: Spontaneous superior ophthalmic vein thrombosis (SOVT) is a rare entity. We describe three patients with spontaneous ophthalmic vein thrombosis, each with various risk factors. PATIENTS AND METHODS: A retrospective review of three patients with a diagnosis of superior ophthalmic vein thrombosis. Clinical characteristics, radiographic features, management techniques and outcomes are described. RESULTS: All patients presented with unilateral painful proptosis. Two patients had intact light perception, whereas one patient presented with absent light perception. All patients had identifiable risk factors for thrombosis, which included sickle cell trait, hereditary hemorrhagic telangectasia and colon cancer with recurrent deep vein thrombosis. Anticoagulation was initiated in two patients. Resolution of proptosis was seen in all patients, with no recovery of vision in one patient. CONCLUSIONS: Risk factors for spontaneous superior ophthalmic vein thrombosis are multifactorial. MRI and MRV confirm the diagnosis of SOVT. Despite urgent intervention devastating visual loss may occur.

Chronic exposure of hydroxyapatite orbital implants: cilia implantation and epithelial downgrowth.

PURPOSE: To describe previously unreported histologic findings in two patients who developed chronic implant exposure and abscess formation within hydroxyapatite orbital implants. METHODS: Surgically removed implant specimens were processed for histopathologic examination and stained for microorganisms. Each patient's clinical course, socket appearance, and exposure management were reviewed. RESULTS: Histopathologic examination of case 1 showed a channel of necrosis leading from the anterior surface of the implant to its center. Hair shafts were discovered embedded within this channel. Histopathologic examination of the site of chronic exposure in case 2 showed epithelial ingrowth into the pores of the implant. Both spheres in this report indicated limited fibrovascular ingrowth and abscess formation. CONCLUSIONS: Chronic exposure of hydroxyapatite implants allows a portal of entry for extraneous hair shafts and also can lead to epithelial downgrowth. Both of these may be contributing factors in the development of serious implant infections.

Small incision nonendoscopic browlift.

PURPOSE: To determine the efficacy of a nonendoscopic brow/forehead lift. METHODS: Case series of 12 patients. Small scalp and upper eyelid blepharoplasty incisions were used to elevate the brows/forehead and perform protractor myectomy. RESULTS: All patients achieved an aesthetically pleasing eyebrow and forehead lift with reduction of vertical and horizontal glabellar creases. Complications included one patient who experienced prolonged ecchymosis after corrugator muscle resection and one patient who had asymmetric lid folds after surgery. The length of follow-up ranged from 9 to 35 months. CONCLUSIONS: The small incision nonendoscopic browlift technique provides a useful alternative to the endoscopic approach.

Repair of orbital floor fractures with hydroxyapatite block scaffolding.

PURPOSE: To determine the efficacy of using a scaffold of hydroxyapatite blocks within the maxillary sinus to treat patients with large orbital floor fractures and secondary vertical globe dystopia. METHODS: Case series of five patients. Hydroxyapatite blocks were stacked within the maxillary antrum to support the reconstructed orbital floor. RESULTS: All patients had good results, though mild residual enophthalmos persisted in three patients. The orbital floor implants and globe positions remained stable during follow-up intervals ranging from 46 to 65 months. No adverse postoperative complications, such as sinusitis, developed. CONCLUSIONS: Hydroxyapatite block scaffolding is a useful alternative to metallic floor implants and autologous bone grafts in the reconstruction of large traumatic orbital floor defects associated with vertical globe dystopia.

Severe vision loss and neovascular glaucoma complicating superior ophthalmic vein approach to carotid-cavernous sinus fistula.

PURPOSE: To report a patient with unilateral vision loss and neovascular glaucoma after attempted superior ophthalmic vein embolization in the treatment of a carotid-cavernous sinus fistula. METHODS: A 69-year-old man with a history of a left dural carotid-cavernous sinus fistula underwent attempted treatment with superior ophthalmic vein embolization. The procedure was unsuccessful, and the left superior ophthalmic vein was ligated. RESULTS: Uncontrolled left proptosis and intraocular pressure necessitated urgent orbital decompression with severe vision loss and neovascular glaucoma. CONCLUSION: Superior ophthalmic vein embolization in the management of carotid-cavernous fistula may be associated with vision-threatening complications.

Lower-eyelid blepharoplasty.

In summary, the concept of one operation for all patients who present for lower-eyelid blepharoplasty should be abandoned. Surgical procedures should be tailored for each individual, depending on the sources of concern and the anatomical defects present. The vast majority of patients are served best by combining transconjunctival blepharoplasty with adjunctive procedures. Transcutaneous lower-lid blepharoplasty has few indications. By combining and choosing the proper techniques, the aesthetics surgeon can achieve lower-eyelid rejuvenation while preserving function and minimizing complications.

Asian blepharoplasty.

Asian blepharoplasty requires an intimate knowledge of the anatomical subtleties distinct to the Asian patient. With this knowledge and a thorough understanding of patients' expectations, the surgeon confidently can achieve predictable results and a preservation of Asian eyelid qualities in those patients who desire it.

Proptosis as the manifesting sign of Weber-Christian disease.

PURPOSE: To identify proptosis as a manifesting sign of Weber-Christian disease (recurrent febrile nodular panniculitis). METHOD: Case report. A 61-year-old man had signs of right proptosis and orbital inflammation that resolved with oral corticosteroid therapy. Orbital inflammation later recurred with associated cutaneous nodules, myalgia, nausea, and malaise. RESULTS: Rheumatologic evaluation and subcutaneous nodule biopsy led to the diagnosis of Weber-Christian disease. The patient required systemic immunosuppressive agents to control the disease. CONCLUSION: This case shows the rare finding of proptosis as the manifesting sign of Weber-Christian disease.

Donor site complications of hard palate mucosal grafting.

The use of hard palate mucosal grafts (HPG) in eyelid surgery is becoming increasingly popular. We present two palatal donor site complications that have not been previously reported. The first is an oro-nasal fistula discovered 1 week following surgery. The second is oral candidiasis, which compromised healing of the palatal donor site. With appropriate treatment, both complications resolved shortly after surgery. Careful preoperative evaluation and postoperative follow-up is recommended to recognize and manage these complications.

Relations of the superficial musculoaponeurotic system to the orbit and characterization of the orbitomalar ligament.

The orbital and eyelid relationships of the superficial musculoaponeurotic system (SMAS) were studied in human cadavers. Using gross and microscopic techniques, the SMAS was found to be intimately related to the eyelids and orbicularis oculi muscle, and to have distinct orbital bony attachments. Sub-SMAS fat in the malar region was found to be continuous with the submuscular fat in the eyebrow region. The malar sub-SMAS fat continued superiorly into the lower eyelid above the inferior orbital rim, as a postorbicularis layer. A bony attachment emanating from the inferior orbital rim, the orbitomalar ligament, traveled through the orbicularis oculi muscle in a lamellar fashion prior to inserting into the dermis. The cutaneous insertion of this attachment corresponds to the malar and nasojugal skin folds. With aging, relaxation of the orbitomalar ligament allows inferior migration of orbital fat, in addition to the anterior migration that occurs through an attenuated orbital septum. These findings have implications not only in cosmetic surgery but also in the understanding of facial soft tissue changes that occur with aging.

Corneal ulcers associated with disposable hydrogel contact lenses.

Four patients developed corneal ulcers associated with the use of disposable extended-wear hydrogel contact lenses. Bacteria were recovered from corneal ulcers in three of the patients. Three patients discarded their contact lenses after ten or more days of extended wear; the corneal ulcers in these patients developed toward the end of the wearing cycle. The fourth patient removed her contact lenses every two days for cleaning and disinfection and discarded them for a new pair on a weekly basis. Improper lens hygiene was noted in only one patient. All corneal ulcers responded to antibiotic treatment. In three patients visual acuity returned to normal, but scarring of one patient's cornea resulted in a visual acuity of 20/60.

Stimulation of noradrenergic sympathetic outflow by calcitonin gene-related peptide.

Alternative splicing of RNA transcripts from the calcitonin gene produces mRNAs that encode different polypeptides. While the mRNA encoding calcitonin predominates in thyroidal 'C' cells, calcitonin gene-related peptide (CGRP) mRNA appears to be the major mRNA component in non-thyroid tissue, including brain. The predicted peptide arising from translation of CGRP mRNA has now been identified immunocytochemically throughout the central and peripheral nervous systems. CGRP, a 37-residue peptide, is distributed in brain pathways subserving sensory, motor and autonomic functions. We report here that CGRP acts in the central nervous system to stimulate selectively noradrenergic sympathetic outflow.