Upper eyelid crease surgical approach to dermoid and epidermoid cysts in children.

The treatment of choice for subcutaneous and orbital dermoid and epidermoid cysts in children is surgical excision. Numerous surgical approaches have been advocated to excise these lesions from the eyelid and anterosuperior orbit. Our technique for this procedure involves an approach through an upper eyelid crease incision. The advantages over alternative methods include (1) excellent exposure of eyelid and anterior orbital structures, (2) familiarity to most eyelid surgeons, (3) minimal dissection with little risk to vital anatomic structures, (4) simple wound closure, and (5) excellent final cosmetic result with a scar that is well-hidden. We have utilized this technique in 24 patients with excellent results and no complications.

Control of corneal astigmatism following cataract extraction by selective suture cutting.

We evaluated the ability of selective suture cutting to reduce postoperative corneal astigmatism in 75 eyes of 68 patients who underwent extracapsular cataract extraction with posterior chamber intraocular lens implantation. Keratometric and refractive measurements were obtained before and at selected intervals (3, 6, 10, 26, and 52 weeks) after surgery. The number of sutures cut during the sixth week after surgery was based on the degree of astigmatism (0.00 to 2.00 diopters (D), no sutures cut; 2.25 to 3.00 D, one suture cut; 3.25 to 4.00 D, two sutures cut; greater than or equal to 4.25 D, three sutures cut). Our analysis demonstrated the following: (1) a spontaneous reduction of 0.5 D in surgically induced astigmatism in eyes without suture cutting, (2) an additional reduction of 1.2 D in postoperative astigmatism for each suture cut, and (3) attainment of 75% to 93% of the total effect of suture cutting within four weeks. The final astigmatism one year after surgery had increased by a mean of 0.9 D, exhibited predominantly with-the-rule properties, and showed no significant difference among the four groups of patients. Vector analysis revealed that only small shifts in the axis of astigmatism occurred after suture cutting. A strong correlation between the keratometric and subjective refractive measurements during all postoperative examinations indicated that corneal astigmatism is primarily responsible for postoperative astigmatism.

Surgical correction of lower-eyelid tarsal ectropion by reinsertion of the retractors.

Lower-eyelid tarsal ectropion is an unusual form of eyelid malposition in which the entire lid is everted. The cause is most likely the disinsertion of the lower-eyelid retractors. In 12 eyelids of six patients, a transconjunctival approach was used to reunite the retractors with the inferior tarsal border. In eight eyelids, a horizontal tightening procedure was also needed. The looping passage of fornix sutures through the full thickness of the eyelid created a vector force that helped rotate the lid margin inward. The subsequent formation of an inflammatory cicatrix induced by the absorbable sutures also contributed to maintain the lid in an upright posture. During follow-up periods ranging from 8 to 36 months, there were no instances of overinversion, recurrent ectropion, or suture abscess.

Sino-orbital aspergillosis in acquired immunodeficiency syndrome.

OBJECTIVE: To describe the clinical features, causes, imaging characteristics, treatment, and outcome of patients with the acquired immunodeficiency syndrome (AIDS) and sino-orbital aspergillosis. DESIGN: Records of 5 patients were reviewed. Results of imaging and histopathologic examinations and clinical courses of the patients were studied. RESULTS: There were 3 women and 2 men (mean age, 34.0 years). All had received a diagnosis of AIDS, and mean CD4+ cell count was 0.014 x 10(9)/L (14 cells/mm3). Computed tomographic scanning exhibited heterogeneous, enhancing sino-orbital soft tissue lesions with bony erosion, and magnetic resonance imaging disclosed soft tissue masses hypointense on T1- and T2-weighted images. The infection involved 1 or more paranasal sinuses, with extension into the right orbit in 3 patients and into the left orbit in 2. Patients were treated with aggressive surgical debridement and intravenous antifungal agents. In addition, local irrigation of amphotericin B was performed in 3 patients. Aspergillus fumigatus was found to be the cause in all 5 patients. Intracranial extension developed in 4 patients, and all subsequently died. The 2 longest surviving patients were the only ones being treated with protease inhibitors. Three patients had a history of frequent marijuana smoking. CONCLUSIONS: Sino-orbital aspergillosis is a progressive, relentless, and usually fatal opportunistic infection of advanced AIDS. Patients are first seen with long-standing headache and proptosis with minimal external inflammatory signs. Marijuana smoking may increase the risk for development of sino-orbital aspergillosis in these patients. Aggressive surgical and medical treatment, combined with newer combination therapies using protease inhibitors, may improve the longevity of these patients.

Optic nerve sheath fenestration for treatment of progressive ischemic optic neuropathy. Results in 26 patients.

Optic nerve sheath fenestration was performed in 26 eyes for treatment of the progressive type of common (nonarteritic) anterior ischemic optic neuropathy. During a mean follow-up period of 21 weeks (range, 6 to 52 weeks), results were as follows: visual acuity increased by two or more lines on the Snellen chart in 7 eyes; visual acuity decreased by two or more lines in four eyes; some regression of visual field defects occurred in six eyes, including two eyes in which acuity also improved. These results, attributed to surgical decompression, do not exceed the spontaneous recovery rates reported in the literature pertaining to nonarteritic anterior ischemic optic neuropathy and fail to substantiate the sanguine visual outcome in recently reported series of patients undergoing optic nerve sheath decompression.

Early revision in the office for adults after unsatisfactory blepharoptosis correction.

The most common complications of levator palpebrae superioris muscle blepharoptosis repair are undercorrection, overcorrection, and abnormalities of the eyelid contour. Previously described nonsurgical as well as surgical methods delay the repair of such complications and introduce the same confounding factors that can affect judgment of the eyelid level as during the initial surgical procedure. Twenty-two patients underwent a highly predictable surgical technique to revise unsatisfactory postoperative eyelid positions. Twenty-five of 26 eyelids (96%) had a satisfactory result and only one of 26 (4%) remained undercorrected. The revision is performed three to four days after the initial blepharoptosis correction and involves blunt separation of the wound without local anesthesia. The levator aponeurosis is advanced or recessed and resutured to the tarsus to achieve the proper eyelid height and contour. The advantages of this revision technique are as follows: (1) the procedure can be quickly and easily performed in the office; (2) the anatomic defects are corrected; (3) sharp dissection, bleeding, and edema are avoided; (4) the technique is painless and usually requires no local anesthetic injections; (5) the tone and function of the levator palpebrae superioris muscle, Müller's, and orbicularis oculi muscles remain undisturbed intraoperatively; and (6) early correction is achieved, thereby enhancing patient acceptance.

Transpalpebral extrusion of a silicone sponge exoplant.

We report an unusual case of scleral buckle extrusion in a 63-year-old woman. A 5 mm silicone sponge exoplant eroded through Tenon's capsule, conjunctiva, and full-thickness upper eyelid, traversing the tarsal plate.

The effects of the ultraviolet-protecting plasmids pKM101 and R205 on DNA polymerase I activity in Escherichia coli K-12.

The mutagenesis- and repair-enhancing plasmids pKM101 and R205 were introduced into a series of Esherichia coli K-12 polA mutants including two temperature-sensitive mutants. Polymerase levels in extracts of these strains were assayed using an activated DNA template. In none of the cases did the presence of the plasmid in the strains change either the initial rate of incorporation of [3H]thymidine triphosphate into acid-soluble material or the subsequent degradation of the template at longer reaction times. Neither did the presence of the plasmids affect the proportion of N-ethylmaleimide-sensitive polymerase activity detected. Previous studies have reported increased polymerase I-like activity of polA mutants of Salmonella typhimurium and Pseudomonas aeruginosa upon introduction of mutagenesis- and repair-enhancing plasmids. Our experiments indicate that, at least, such an increase in polymerase-I-like activity is not an obligatory phenotype associated with these plasmids.

Treatment of periorbital Molluscum contagiosum by incision and curettage.

Molluscum contagiosum, caused by a double-stranded DNA virus, is found world-wide, affecting humans as well as other primates and marsupials. In humans, a biphasic incidence occurs with peak infection rates among young children and young adults. In children, infection is spread by direct contact or through fomites, with lesions predominating on the trunk, extremities, and face. In young adults, this disease is spread primarily through sexual contact. Periocular infection can cause secondary chronic follicular conjunctivitis, superficial keratitis, and punctal occlusion. Although many modes of therapy are effective in destruction of the virus, some may have significant side effects when used in the periocular area. We describe treatment by incision and curettage, which we recommend as a simple, effective method of managing this problem.

Eyelid necrosis and periorbital necrotizing fasciitis. Report of a case and review of the literature.

Necrotizing fasciitis is an uncommon and severe soft tissue infection characterized by cutaneous gangrene, suppurative fasciitis, and vascular thrombosis. The disease is usually preceded by trauma in patients that have systemic problems, most commonly diabetes and alcoholism. Streptococcus pyogenes and Staphylococcus aureus are the most frequent bacterial etiologies; however, combinations of numerous facultative and anaerobic organisms have also been isolated. Involvement of the face and periocular region is rare. A case is presented here, as well as a review of the clinical features of 15 other patients previously described, in whom eyelid necrosis due to periorbital necrotizing fasciitis developed. Early surgical debridement and drainage of necrotic tissues and appropriate parenteral antibiotics are the mainstay of therapy. The mortality rate in patients with periorbital spread was 12.5%, with the prognosis known to be adversely affected by delay in diagnosis and treatment and/or extension of infection from the face to the neck. Reconstruction of the eyelids with skin grafts was necessary in most cases to avoid such complications as cicatricial lid retraction, lid malpositions, and lagophthalmos.

Vertically oriented upper eyelid nerve fibers. A clinical, anatomical and immunohistochemical study.

Vertically oriented suborbicular nerve fibers are frequently encountered during upper eyelid surgery. It has not been well established whether these fibers are terminal motor branches of the facial nerve (VII) or sensory branches of the ophthalmic nerve (V-1). To investigate the origin of these nerve fibers, three different techniques were used: (1) intraoperative nerve stimulation; (2) cadaver dissection; and (3) immunohistochemical analysis. The results of all three investigative methods are in agreement and conclusively demonstrate that these fibers represent sensory branches of the ophthalmic nerve (V-1) and not motor branches of the facial nerve (VII). Anatomical dissection showed that the sensory fibers to the upper eyelid do not travel solely within the suborbicular fascial plane, but also course in the preorbicular plane and within the orbicularis muscle itself. The terminal branches of the facial nerve to the upper eyelid innervate the orbicularis oculi from the undersurface and in a horizontal orientation. Clinical correlation of these findings is discussed.

Magnetic resonance imaging of the orbit. Part I. Physical principles.

Magnetic resonance has twin capabilities. It can provide anatomical (magnetic resonance imaging, MRI) and physiochemical (magnetic resonance spectroscopy) information. Nuclei with an odd mass number, particularly hydrogen in free water, have electromagnetic properties. When placed in a strong static magnetic field and excited by radiofrequency waves of a specific wavelength, these nuclei emit a signal. The MR signal can then be digitized, stored in a computer, and subsequently converted into an image. Factors that affect these images are tissue parameters (T1 and T2 time constants, proton density, and flow) and radiofrequency pulse sequences. Surface coils are useful for improving images of the orbit. The magnet can have a major and potentially dangerous influence on the surrounding environment, and access to the MRI area must be carefully controlled. Shielding of the MRI room prevents external factors from adversely affecting the MRI unit and the images produced.

Magnetic resonance imaging of the orbit. Part II. Clinical applications.

Imaging of the orbit with magnetic resonance imaging (MRI) provides better anatomic detail with T1-weighted sequences and superior visualization of pathologic conditions with T2-weighted sequences. Compared with computerized tomography (CT), MRI has the following advantages: lack of ionizing radiation, direct multiplanar imaging, better contrast resolution, lack of bone artifacts, visualization of bone marrow, superior study of certain neurological disorders, and spectroscopy. Compared with CT, MRI has the following disadvantages: prolonged examination, poorer ability to detect orbital calcifications and cortical bone destruction, poorer spatial resolution, fewer suitable patients, certain image artifacts, high cost of MRI units, and higher cost of MRI examinations.

Temporal artery biopsy technique: a clinico-anatomical approach.

A positive temporal artery biopsy is required to conclusively establish the diagnosis of temporal arteritis. The temporal artery biopsy technique we describe is based on the anatomical branching patterns of the superficial temporal artery, the various fascial layers, and the location of the temporal branches of the facial nerve. Special emphasis is placed on avoiding facial nerve trauma during a biopsy of the frontal branch of the superficial temporal artery. Proper surgical technique combined with a working knowledge of the anatomy of the temporalis region enhances the safety of a temporal artery biopsy procedure.