Treatment of blepharospasm with botulinum toxin. A preliminary report.

The effects of botulinum A toxin injections for the treatment of facial spasm were analyzed for 22 patients. Sixteen patients had unoperated on essential blepharospasm, three had essential blepharospasm with residual spasm following previous surgical treatment, and three had unoperated on hemifacial spasm. Treatment was effective for most patients, but transient, with the mean interval of relief of spasm after the first injections being ten weeks. The injection of botulinum toxin reduced the maximum lid force by about 10%. While side effects were common, they were generally mild and well tolerated. No cumulative effect of botulinum toxin was evident in those receiving three series of injections. There is no significant difference in either the interval free of spasm or the rate of lid-force recovery following any of three sequential injections of increasing doses of botulinum toxin.

Myoepithelioma of the lacrimal gland.

A right orbital tumor was excised from a 76-year-old woman. Pathological examination showed that the tumor was composed of spindle to cuboidal cells arranged in a solid to trabecular pattern. Immunohistochemical stains were positive for S-100 protein, muscle-specific actin, cytokeratins MAK6 and AE1,3, and glial fibrillary acid protein and negative for CD34 in tumor cells. Ultrastructural features of tumor cells included microvillous processes, intercellular junctions, and intracytoplasmic filaments with electron densities. To our knowledge, this is the first non-spindle cell myoepithelioma noted to arise in the lacrimal gland. This tumor likely has a similar biological behavior to pleomorphic adenoma (benign mixed tumor).

Kimura disease of the orbit and ocular adnexa.

Kimura disease (KD) is a distinct clinicopathologic entity that has been the subject of considerable confusion and debate. Although common in Asia, KD rarely occurs in non-Asian patients. Kimura disease shares both clinical and histopathologic features with angiolymphoid hyperplasia with eosinophilia (ALHE). Because of this overlap and the rarity of KD in Europe and the United States, KD and ALHE have been used synonymously in the Western medical literature, as they were thought to represent variations of the same disease. Some pathologic reports have called for distinguishing KD and ALHE as two separate entities, based on their histologic features. Kimura disease occurs most commonly in the head and neck region and has been described in the orbit, eyelids, and lacrimal gland more frequently than ALHE. Because both diseases can cause proptosis, lid swelling, ocular dysmotility, or a palpable mass, they should be considered in the differential diagnosis of orbital lesions occurring in adults. We report two cases of KD involving the orbit and ocular adnexa, and review additional cases reported in the literature. The ophthalmic literature does not clearly reflect the current understanding that KD and ALHE are best considered two separate clinicopathologic entities.

Allergic lacrimal obstruction.

Five patients with ocular allergy and intermittent epiphora had a temporary obstruction at the level of the lacrimal sac or canaliculus. The obstruction probably resulted from mucosal edema induced by rubbing the pruritic periocular tissues, a maneuver commonly performed by such patients. Treatment was aimed at inhibiting the allergic response with cromolyn sodium eyedrops, and patients were instructed to refrain from rubbing the periocular tissues.

Metastatic esophageal carcinoma to the orbit.

PURPOSE: To report a case of esophageal adenocarcinoma and areas of gastric differentiation in the esophagus (Barrett esophagus) metastatic to the orbit. METHODS: A 47-year-old man with a history of esophageal carcinoma developed turgescence around his left eye. He underwent a biopsy and histologic examination of a left orbital mass. RESULTS: Histopathology of the orbital tumor was consistent with metastatic adenocarcinoma from the esophagus. CONCLUSIONS: This metastatic adenocarcinoma to the orbit likely arose in Barrett esophagus.

Bone formation in hydroxyapatite orbital implants.

PURPOSE: We examined the histopathologic features of two hydroxyapatite orbital implants that were removed from two patients. METHODS: Two surgically removed hydroxyapatite orbital implants were decalcified and processed for routine light microscopic examination. RESULTS: Both implants demonstrated fibrovascular ingrowth and foci of bone formation. CONCLUSION: Bone may form in hydroxyapatite orbital implants.

Osseous metaplasia in proliferative vitreoretinopathy.

PURPOSE: To report the clinicopathologic features of intraocular osseous production in association with proliferative vitreoretinopathy. METHOD: The clinical and histopathologic features of two patients with proliferative vitreoretinopathy and intraocular bone formation are reviewed. RESULTS: Preretinal osseous tissue incorporated in the proliferative vitreoretinopathy was surgically removed in one patient, and osseous tissue was present in the proliferative vitreoretinopathy in the enucleated eye of the other patient. CONCLUSIONS: Bone formation, presumably from metaplastic retinal pigment epithelium, may be present in proliferative vitreoretinopathy tissue. The intraocular bone is present internal rather than external to the neurosensory retina.

Pneumococcal endophthalmitis associated with nasolacrimal obstruction.

Pneumococcal endophthalmitis can be a devastating postoperative infection after cataract extraction or penetrating keratoplasty. Streptococcus pneumoniae was isolated as the causative agent in three of the 124 patients (2%) who were treated for endophthalmitis at our institution between 1984 and 1990. Two of the three patients lost light perception in the affected eye. All three patients had previously unrecognized or untreated chronic nasolacrimal obstruction of varying causes. We studied the role of pneumococcal lacrimal conjunctivitis in the pathogenesis of the postoperative pneumococcal endophthalmitis in these patients.

The incidence of extraocular muscle and cranial nerve palsy in orbital floor blow-out fractures.

The frequency of extraocular muscle (EOM) or cranial nerve (CN) palsy as the sole cause of diplopia in orbital floor blow-out fractures has not been previously determined. Of 40 blow-out fracture patients studied prospectively, seven had motility disturbances consistent with palsy of one EOM or CN. All seven patients had negative forced ductions, making entrapment, edema, or orbital hemorrhage unlikely causes of diplopia. The diplopia resolved in four patients in 1 year. Persistent diplopia is a common indication for repair of such fractures. If, however, diplopia is due only to EOM or CN palsy, orbital surgery should be deferred (in the absence of significant enophthalmos) in favor of observation and/or later strabismus surgery.

Congenital dacryocystocele in identical twins.

Identical twins were found to have unilateral congenital dacryocystoceles. Both were immediately probed, which resulted in resolution of one and recurrence in the second twin. The recurrent dacryocystocele was reprobed and the abnormality was resolved. Etiology and management are discussed.

Lid splitting with lash resection for cicatricial entropion and trichiasis.

Lid margin splitting at the gray line with resection of the lash-bearing anterior lamella of the eyelid is a simple and effective treatment for cicatricial entropion and trichiasis. Twenty-six patients underwent this procedure with good results.

Downgaze ptosis.

In involutional blepharoptosis, an abnormally low lid position in primary gaze is accompanied by increased lid excursion in downgaze. Described here are four patients with little or no ptosis in primary position but significant and symptomatic obstruction of the visual axis in downgaze only. All responded well to minimal aponeurotic advancement with sufficient elevation of the lids in downgaze to allow reading but with little or no discernible change of the lids in primary position. This "downgaze ptosis," not previously described, may be an early stage of typical involutional ptosis.

The association between cigarette smoking and basal cell carcinoma of the eyelids in women.

PURPOSE: To determine if there is an association between basal cell carcinoma of the eyelid and cigarette smoking. METHODS: A cross-sectional, retrospective, case-controlled study was done comparing the prevalence of cigarette smoking in 112 patients with biopsy-proven basal cell carcinoma of the eyelid to age and sex-matched controls with other eyelid disorders. Exposure-odds ratios were computed for each group. RESULTS: Patients with basal cell carcinoma of the eyelid were no more likely to be smokers than controls (odds ratio [OR] 1.78, not statistically significant at the 95% confidence interval [CI]). When divided by sex however, there was an association between cigarette smoking and basal cell carcinoma in women (OR 2.87, statistically significant at the 95% CI) but not in men (OR 1.30, not statistically significant at the 95% CI). CONCLUSION: Basal cell carcinoma of the eyelid is associated with cigarette smoking in women but not in men.

Sotradecol (sodium tetradecyl sulfate) injection of orbital lymphangioma.

PURPOSE: To describe the results of intralesional injection of the sclerosing agent sodium tetradecyl sulfate in patients with lymphangioma. METHODS: Three patients (one child and two adults) were treated. RESULTS: Two patients had improvement in the size of the lymphangioma, although the result was short-lived in one instance. Minimal change was noted in the third patient. Two patients had transient edema and ecchymosis, and one patient had a mild allergic reaction to the injected solution. CONCLUSIONS: Sodium tetradecyl sulfate may be a useful therapeutic option for some patients with eyelid or orbital lymphangioma, particularly if a previous operation has not been performed.

Inflammatory pseudotumor of the eyelid.

We present three patients whom we believe developed idiopathic inflammatory pseudotumors confined to the eyelid tissues with no evidence of orbital involvement. All three patients were misdiagnosed initially as having lesions of an infectious etiology. All three patients responded completely and rapidly to oral steroid therapy after the correct diagnosis was confirmed by biopsy. We believe that pseudotumor of the eyelid is a distinct subtype of idiopathic inflammatory pseudotumor.