Lacrimal function tests.

A comparative study of lacrimal function tests was undertaken. The primary Jones fluorescein test, the fluorescein dye disappearance (FDD) test, the Hornblass saccharin taste test and the Schirmer secretory test were tested for their reliability and effectiveness in 60 lacrimal systems with no known pathologic history or physical findings. Schirmer test values diminish with advancing age. The correlation between the FDD test, the Jones fluorescein test, and the saccharin taste test was low. The FDD test is an unsatisfactory test. The saccharin taste test time was shorter in patients with a positive Jones fluorescein test and longer in patients with a negative Jones fluorescein test. Forty-eight percent or 31/60 lacrimal systems had a negative Jones fluorescein test. This is higher than previously reported. The saccharin taste test was found to be the most practical and reliable of all lacrimal excretory function tests despite its subjectivity.

Orbital neurofibromatosis: involvement of the orbital floor.

Neurofibromatosis has been reported to involve the eye and orbit by causing irregularities of the sphenoid and other facial bones and enlargement of the foramina. To our knowledge, abnormalities of the orbital floor, however, have not been attributed to this disease in the literature until now. Two patients with neurofibromatosis had orbital floor involvement. Multiple neurofibromas eroding the orbital floor threatened vision in one patient. The other case, seen after trauma, had a condition simulating that of a blow-out fracture. Diagnostic workup with adequate roentgenography, especially tomography, helped to establish the diagnosis. We believe this is of importance in modifying the surgical approach, obviating the need for surgical intervention at times.

Autogenous dermis-fat orbital implantation.

We examined 52 consecutive patients who underwent autogenous dermis-fat implantation in anophthalmic sockets during the past five years. The results of the study show that 81% of the cases had no change in the volume of the graft during a mean follow-up period of 2 1/2 years, ranging from a minimum of six months to a maximum of five years. The remaining 19% underwent graft resorption to a varying degree. We consider dermis-fat graft a procedure of choice in cases of extruded or migrated implants, an alternative to a synthetic allograft in primary enucleations, and a useful procedure in selected cases of enophthalmic and contracted socket.

Elastofibroma oculi.

A 69-year-old woman had a placoid lesion extending from the temporal limbus with a ptyergioid head to involve extensively the temporal epibulbar conjunctiva, the superolateral and inferolateral fornices, and the lateral canthus. It was composed of thickened bundles of collagen, scattered islands of adipose tissue, and abundant refractile linear elastinophilic structures. Electron microscopy confirmed that the elastinophilic structures were mature elastic fibers embedded within markedly thickened bundles of collagen. This lesion resembles elastofibromas that occur in a subscapular location. Elastofibroma oculi is distinguishable from the more common pterygium and pinguecula by the sparing of the immediate subepithelial zone of the conjunctiva, which is preferentially involved by these other lesions, and by failure to exhibit ultrastructurally microfibrillar aggregates and dystrophic elastic fibers. Both the elastic fibers and thickened bundles of collagen in the elastofibroma are presumed to have arisen from activated fibroblasts.

Sebaceous carcinoma of the ocular adnexa.

Sebaceous carcinoma accounts for 1-5.5% of all eyelid malignancies. This lesion, traditionally considered among the most lethal of all tumors of the ocular adnexa, occurs more commonly in women and in the elderly and has a predilection for the upper lid. Both clinically and histologically, sebaceous carcinoma may masquerade as benign or less invasive conditions such as chalazion, blepharitis, conjunctivitis, meibomitis, superior limbic keratoconjunctivitis, basal cell carcinoma and carcinoma in situ, resulting in delayed diagnosis and treatment. In this review the incidence, clinical presentation, and prognostic factors (both clinical and histopathologic), and treatment modalities are discussed.

Squamous cell carcinoma of the eyelid.

The occurrence of squamous cell carcinoma of the lid is reviewed with emphasis upon the incidence, clinical presentation, pathophysiology and methods of treatment. Squamous cell carcinoma accounts for about 9% of all eyelid malignancies, although it is frequently over-diagnosed by pathologists and confused histologically with other benign entities. This lesion occurs most commonly in elderly, fair-complexioned individuals with a history of chronic sun exposure and skin damage. In the lids, squamous cell carcinoma shows a variety of clinical appearances although it usually presents as a painless, hyperkeratotic lesion that gradually enlarges and eventually ulcerates. There is a tendency for lower lid and lid margin involvement. This potentially lethal neoplasm is capable of aggressive local spread or metastasis to regional lymph nodes. The development of squamous cell carcinoma is thought to progress through phases of intraepithelial squamous dysplasia and intraepidermal squamous cell carcinoma before invasive squamous cell carcinoma occurs. Various treatment modalities have been advocated including surgical extirpation with histologic control, radiation therapy and cryotherapy.

Orbital abscess.

Although orbital or subperiosteal abscess may originate from a number of sources, paranasal ethmoidal sinus disease is the most common source of infection, particularly in children. Prompt diagnosis and treatment are necessary to prevent severe visual loss and even death. The authors review the five-group classification of orbital abscess and summarize data regarding source, bacteriology, treatment and visual results from 13 series reporting 148 patients. Four new cases are presented in detail. Diagnostic procedures, including laboratory testing, sinus radiography, ultrasound and CT scanning, are discussed and recommendations are given for medical and surgical management.

Ablepharon macrostomia syndrome.

The ablepharon macrostomia syndrome is a severe congenital condition that includes total absence of the upper and lower eyelids, failure of lip fusion that results in an enlarged, fish-like mouth, abnormally shaped ears and nose, absence of lanugo, ventral hernia, and ambiguous genitalia. In one such patient we were able to reconstruct the eyelids in a three-stage procedure. Redundant skin from the retroauricular area was used to create full-thickness grafts. The child later underwent successful mouth reconstruction. Although developmentally delayed, the child was eventually able to sit unassisted, to grasp objects, and to follow light with some fixation. Nystagmus was severe. The retina was attached in one eye and detached in the other. Corneal opacities present initially improved in one eye, allowing a view of the pupil and a normal anterior chamber.

Carbon dioxide laser surgery in hemophilia.

We used a carbon dioxide laser to remove a subcutaneous lipoma from the brow of a patient with classical hemophilia A. This technique made the cosmetic procedure safe and effective in a patient for whom surgery would otherwise have held a greater risk.

Pigmented basal cell carcinoma of the eyelids.

In a retrospective study of 100 cases of basal cell carcinoma treated by surgical excision, we found nine pigmented lesions. The clinical diagnosis of pigmented basal cell carcinoma of the eyelid was rarely considered and the lesion was often misdiagnosed as a melanoma. The pigmented basal cell carcinoma was no different from the nonpigmented basal cell carcinoma with respect to the sex and age of the patients and the locations, durations, and recurrence rates of the lesions.

Eyelid and orbital cavernous hemangioma associated with keratoconus.

A 38-year-old man had a 35-year history of a slowly progressive eyelid and orbital mass and keratoconus affecting his left eye. The mass was excised and found to be a large encapsulated cavernous hemangioma. We postulated a direct relationship between the development of keratoconus and the mechanical pressure exerted by the tumor on the globe.

Ectopic epibulbar Fordyce nodules in a buccal mucous membrane graft.

A 70-year-old man underwent oral mucous membrane grafts to the right eye for presumed trachoma at the ages 26 and 32 years. A superior limbic mass within the site of the graft was found in 1983; the mass was composed of mature sebaceous glands compatible with the lesions called Fordyce nodules when located in the buccal mucosa. Recession of the levator aponeurosis and partial excision of the mass restored the upper eyelid's normal position, and visual acuity in this eye improved from 20/300 to 20/40.

The treatment of advanced choroidal melanoma with massive orbital extension.

Four patients, each with a history of choroidal melanoma for more than ten years, became increasingly proptotic secondary to massive extraocular extension of their tumors. Because no metastases were detected during thorough systemic examinations, two patients underwent orbital exenteration. These patients suffered fulminant local orbital regrowth of their tumors at three and six months after surgery and died of distant metastases within ten months of exenteration. A third patient, who underwent a biopsy of the orbital mass via a lateral orbitotomy and received postoperative radiotherapy, died two years afterward. A fourth patient who refused any surgical treatment was followed up for five years after massive orbital disease developed. She died of disseminated disease. The patients who survived the longest had minimal or no surgery.

Surgical correction of entropion and ectropion in the same lid.

A patient with medial ectropion and lateral entropion of the same lower lid is presented, and the surgical management of this unusual condition utilizing a horizontal lid-shortening, orbicularis sling procedure, fixation of the posterior and anterior lamellae of the lid, and resection of the tarsal conjunctival layer is described. We believe that the key to the successful management of this condition lies in treating each component surgically as if it were a separate entity, and by using a combination of surgical techniques, both eyelid malpositions can be corrected.