Frozen Section Histoanatomy of the Peritarsal Eyelid.

BACKGROUND: Mohs surgery of eyelid skin cancers requires detailed knowledge of anatomy for precise surgery and accurate evaluation of histology. OBJECTIVE: To review the histology of the peritarsal eyelid using frozen sections as encountered intraoperatively by Mohs surgeons. METHODS: The authors review the literature describing the anatomy and histology of the peritarsal eyelid from the lens of a Mohs surgeon. Histology from select Mohs cases is used to frame the discussion of the microanatomy of this region. RESULTS: The peritarsal eyelids contain a unique mixture of skin, muscle, tarsus, glandular tissue, and conjunctiva. The histologic appearance of many of these structures differs from skin found outside of this anatomic region. Tumors of the eyelid and periocular region may mimic normal histologic structures found within the peritarsal eyelid. CONCLUSION: The peritarsal eyelids have unique anatomy and associated histologic structures. Knowledge of the detailed histoanatomy is required for confident execution of Mohs surgery in this anatomic region.

Cavernous sinus thrombosis with bilateral orbital vein involvement and diffuse ischemic retinopathy / Trombose do seio cavernoso com envolvimento bilateral das veias orbitais e retinopatia isquêmica difusa

ABSTRACT A 53-year-old man with a 3-day history of periorbital swelling and vision loss in the left eye was found to have septic cavernous sinus thrombosis with bilateral orbital vein involvement causing congestive orbitopathy. He was treated with an emergent canthotomy and cantholysis, intraocular pressure-lowering drops, antibiotics, anticoagulation, and serial examinations. Optical coherence tomography ultimately revealed diffuse ischemic destruction of both layers of the retina, which suggested occlusion of the ophthalmic artery or the short posterior ciliary arteries and central retinal artery without intracavernous internal carotid artery involvement. The patient remained without light perception in the left eye after treatment.

RESUMO Um homem de 53 anos, com história de 3 dias de edema periorbital e perda de visão no olho esquerdo, apresentou trombose séptica do seio cavernoso com envolvimento bilateral das veias orbitais, causando uma orbitopatia congestiva. O paciente foi tratado com uma cantotomia e cantólise de emergência, colírios para redução da pressão intraocular, antibióticos, anticoagulantes e exames seriados. A tomografia de coerência óptica finalmente demonstrou destruição isquêmica difusa de ambas as camadas da retina, sugerindo uma oclusão da artéria oftálmica ou das artérias ciliares posteriores curtas e da artéria retiniana central, com ausência de envolvimento do segmento intracavernoso da artéria carótida interna. O paciente permaneceu sem percepção luminosa no olho esquerdo.

Cavernous sinus thrombosis with bilateral orbital vein involvement and diffuse ischemic retinopathy.

A 53-year-old man with a 3-day history of periorbital swelling and vision loss in the left eye was found to have septic cavernous sinus thrombosis with bilateral orbital vein involvement causing congestive orbitopathy. He was treated with an emergent canthotomy and cantholysis, intraocular pressure-lowering drops, antibiotics, anticoagulation, and serial examinations. Optical coherence tomography ultimately revealed diffuse ischemic destruction of both layers of the retina, which suggested occlusion of the ophthalmic artery or the short posterior ciliary arteries and central retinal artery without intracavernous internal carotid artery involvement. The patient remained without light perception in the left eye after treatment.

Seven-Year Follow-Up of a Patient With a Retained Needlefish Jaw Fragment Abutting Against His Left Internal Carotid Artery.

ABSTRACT: A 51-year-old man presented to the ophthalmology service with binocular diplopia and facial numbness. The patient was returning from a trip to Mexico. He reported having been hit in the left periocular region by a fish while swimming. Local doctors repaired a laceration in the left lateral canthus shortly after the incident. Orbital imaging revealed 2 needle-like foreign bodies corresponding to retained pieces of a needlefish jaw in the left orbit. Given the location of the foreign bodies, observation with repeat imaging was deemed more appropriate than surgical exploration. Subsequent imaging studies showed no migration of the foreign body, and the patient did not suffer from any related complications more than 7 years after the initial injury.

Regression of Sebaceous Carcinoma of the Eyelid after a Small Incisional Biopsy: Report of Two Cases.

PURPOSE: To report 2 cases of regression of sebaceous carcinoma of the eyelid after a small incisional biopsy. METHODS: Clinical, imaging, and histopathological findings are presented, with a literature review on regressing ocular tumors. RESULTS: Our first patient was a 79-year-old man who presented with a 10-month history of progressive left upper eyelid ptosis caused by an eyelid tumor with orbital involvement and confirmed on magnetic resonance imaging. Our second patient was a 70-year-old woman who presented with ptosis with a left upper eyelid mass. Both patients underwent a small incisional biopsy of their lesion. The histopathological diagnoses in both cases were consistent with sebaceous carcinoma. Both patients refused exenteration. Follow-up clinical examination and imaging disclosed total regression of the ptosis and of the neoplasm with no sign of recurrence in both patients over a 4-year period for Case 1 and a 7-year period for Case 2. CONCLUSION: Regression following incisional biopsy of basal cell, squamous cell, and Merkel cell carcinoma, including of the eyelid, is well documented. To the best of our knowledge, our 2 cases of sebaceous carcinoma are the first to be reported with total involution clinically and on imaging of the tumor following partial incisional biopsy.

Is gastroesophageal reflux disease associated with primary acquired nasolacrimal duct obstruction?

PURPOSE: To determine if patients with primary acquired nasolacrimal duct obstruction (PANDO) have an increased prevalence of gastroesophageal reflux disease (GERD) compared to the general population. METHODS: Cross-sectional case-control study. The Mayo Clinic Reflux Disease Questionnaire (RDQ) is used to help physicians diagnose GERD. The retrospective group consisted of patients who previously had a dacryocystorhinostomy (DCR) over a 4-year period by one surgeon (JTH) at one institution. The prospective group included consecutive patients undergoing DCR over an 8-month period for PANDO. The control group consisted of patients at our institution who did not have complaints related to nasolacrimal duct obstruction (NLDO) or a known history of NLDO. The RDQ score or a previous diagnosis of GERD was recorded for each patient. The prevalence of patients with GERD in each of the groups was compared to that in the control group using the Fisher exact test. RESULTS: Nine (7.7%) of 117 patients in the control group were found to have GERD. Twenty-four of 65 (36.9%) patients in the retrospective cohort were found to have GERD. Twelve of 18 (66.7%) patients in the prospective cohort were found to have GERD. When the prospective and retrospective groups were compared to the control group, the presence of GERD was higher in patients with NLDO (p < .0001). CONCLUSION: Based on the results of this study and compared to the general population, GERD has an increased prevalence in patients with PANDO. GERD may have a role in the development of PANDO.

Orbital ultrasonography in the diagnosis of neoplastic extraocular muscle enlargement.

Neoplastic infiltration of the extraocular muscle (EOM) is a rare condition which can pose a diagnostic dilemma due to its rarity and overlapping ultrasonographic features with orbital myositis. The ultrasonographic features of neoplastic enlargement of EOM have not been systematically studied and previously have been described in only a few case reports. Orbital ultrasonography, in conjunction with the pattern of ocular misalignment, was assessed for its potential role in identifying patients with neoplastic EOM enlargement. Retrospective chart review of patients with neoplasm and myositis. The clinical features of 8 patients with neoplastic infiltration of the EOM were compared to 15 patients with myositis. In the neoplastic group the width of the EOM was (10.5 mm) almost twice the normal width of the muscle with myositis (p < 0.001). All the muscles in the neoplastic category were low to medium reflective. Paretic deviation was seen in 4/8(50%), purely restrictive in 2/8 (25%) and combined pattern in 2/8 (25%) were noted. In the myositis group the average EOM enlargement was 5.8 mm and all muscles showed low reflectivity. Although ultrasonographic features overlapped between the 2 groups paretic deviations were more common in the neoplastic group versus the myositis group (50% versus 7%). Neoplastic muscle enlargement tends to be larger with paretic deviations of ocular motility seen clinically. These findings in a patient with EOM enlargement should raise the suspicion of neoplasm as the etiology and further work up should be considered.

Two- versus four-handed techniques for endonasal resection of orbital apex tumors.

BACKGROUND: Open versus endonasal resection of orbital apex (OA) tumors is generally based on tumor size, location, and pathology. For endonasal resection, two- and four-handed techniques have been reported, but whether one technique is more optimal based on these tumor features has not been evaluated. OBJECTIVE: To determine whether two- versus four-handed techniques result in better outcomes after endoscopic resection of OA tumors, and whether either technique is better suited for intra- versus extraconal location and for benign versus malignant pathology. METHODS: A retrospective review of all expanded endonasal approaches for OA tumors was performed at a single institution from 2009 to 2013. A PubMed database search was also performed to review series published on endonasal OA tumor resection. Across all the cases reviewed, the following data were recorded: two- versus four-handed techniques, intra- versus extraconal tumor location, and benign versus malignant pathology. The relationship between these variables and resection extent was analyzed by the Fisher exact test. Postoperative visual status and complications were also reviewed. RESULTS: Ten cases from the institution and 94 cases from 17 publications were reviewed. Both two- and four-handed techniques were used to resect extra- and intraconal OA tumors, for both benign and malignant pathology. Four-handed techniques included a purely endonasal approach and a combined endonasal-orbital approach. On univariate analysis, the strongest predictor of complete resection was benign pathology (p = 0.005). No significant difference was found between the extent of resection and a two- versus a four-handed technique. Visual status was improved or unchanged in 94% of cases, and other complications were rare. CONCLUSION: Benign tumors that involve the medial extraconal and posterior inferomedial intraconal OA can be treated by either two- or four-handed endonasal techniques. Selecting two- versus four-handed techniques and endonasal versus endonasal-orbital four-handed techniques depends mainly on surgeons' experience. Endonasal approaches for malignant OA tumors are less likely to result in complete resection.

Oculoplastic surgery.

Esthetic and functional surgery in the periocular region falls into the domain of oculoplastic surgeons, as well as plastic surgeons and otorhinolaryngologists with training in facial plastic surgery. This article provides a description of 8 common eyelid procedures that are routinely performed under local anesthesia, with or without mild intravenous sedation. Serious complications are rare. The rate of postoperative infection in the highly vascularized eyelid tissues is less than 1% in our experience.

Complications of blepharoplasty: prevention and management.

Blepharoplasty is an operation to modify the contour and configuration of the eyelids in order to restore a more youthful appearance. The surgery involves removing redundant skin, fat, and muscle. In addition, supporting structures such as canthal tendons are tightened. Other conditions such as ptosis, brow ptosis, entropion, ectropion, or eyelid retraction may also need to be corrected at the time a blepharoplasty is performed to ensure the best functional and aesthetic result. Due to the complexity and intricate nature of eyelid anatomy, complications do exist. In addition to a thorough pre operative assessment and meticulous surgical planning, understanding the etiology of complications is key to prevention. Finally, management of complications is just as important as surgical technique.

Metastasis of uveal melanoma millimeter-by-millimeter in 8033 consecutive eyes.

OBJECTIVE: To determine the rate of metastasis of uveal melanoma on the basis of tumor thickness in millimeters. METHODS: Retrospective medical record review. RESULTS: The mean (median) patient age was 58 (59) years. A total of 8033 eyes were examined. Of the 285 eyes with iris melanoma, the mean tumor thickness was 2.7 mm and metastasis occurred in 0.5%, 4%, and 7% at 3, 5, and 10 years, respectively. Of the 492 eyes with ciliary body melanoma, the mean tumor thickness was 6.6 mm and metastasis occurred in 12%, 19%, and 33% at 3, 5, and 10 years, respectively. Of the 7256 eyes with choroidal melanoma, the mean tumor thickness was 5.5 mm and metastasis occurred in 8%, 15%, and 25% at 3, 5, and 10 years, respectively. For all uveal melanoma, metastasis at 5, 10, and 20 years was 6%, 12%, and 20% for small melanoma (0-3.0 mm thickness), 14%, 26%, and 37% for medium melanoma (3.1-8.0 mm), and 35%, 49%, and 67% for large melanoma (>8.0 mm). More specifically, metastasis per millimeter increment at 10 years was 6% (0-1.0 mm thickness), 12% (1.1-2.0 mm), 12% (2.1-3.0 mm), 16% (3.1-4.0 mm), 27% (4.1-5.0 mm), 28% (5.1-6.0 mm), 29% (6.1-7.0 mm), 41% (7.1-8.0 mm), 50% (8.1-9.0 mm), 44% (9.1-10.0 mm), and 51% (>10.0 mm). Clinical factors predictive of metastasis by multivariate analysis included increasing patient age, ciliary body location, increasing tumor diameter, increasing tumor thickness, having a brown tumor, and the presence of subretinal fluid, intraocular hemorrhage, or extraocular extension. CONCLUSION: Increasing millimeter thickness of uveal melanoma is associated with increasing risk for metastasis.

Optical coherence tomography of choroidal osteoma in 22 cases: evidence for photoreceptor atrophy over the decalcified portion of the tumor.

PURPOSE: To evaluate the retinal status overlying choroidal osteoma using optical coherence tomography (OCT). DESIGN: Retrospective noncomparative case series. PARTICIPANTS: Twenty-two eyes with choroidal osteoma. METHODS: Choroidal osteoma was studied with fundus photography, ultrasonography, and OCT. MAIN OUTCOME MEASURE: Retinal status over the calcified and decalcified portions of choroidal osteoma. RESULTS: There were 8 completely calcified and 14 partially decalcified choroidal osteomas. Optical coherence tomography was performed over the calcified portion in 21 eyes and over the decalcified portion in 10 eyes. The calcified portion displayed an overlying intact inner retina (n = 21 [100%]), intact outer retina (n = 20 [95%]), and intact photoreceptor layer (n = 21 [100%]). In contrast, the decalcified portion showed an intact inner retina (n = 9 [90%]) and markedly thinned to absent outer retina and photoreceptor layers (n = 10 [100%]). Of the 18 eyes with subfoveolar choroidal osteoma, visual acuity (VA) was 20/20 to 20/50 in all 11 eyes with calcified tumor, and OCT confirmed preservation of retinal architecture. In contrast, VA was 20/200 or worse in all 7 eyes with subfoveolar decalcified tumor, correlating with OCT findings of outer retinal thinning and photoreceptor loss. CONCLUSIONS: The retina shows profound outer layer thinning and photoreceptor loss over decalcified choroidal osteoma. These findings correlate with poor VA over decalcified subfoveolar choroidal osteoma compared with good VA over calcified subfoveolar tumor.