Solitary Langerhans Cell Histiocytosis of the Palpebral Conjunctiva Presenting as Leukoplakia: Case and Review of Literature.

A 69-year-old male presented with a superior palpebral conjunctival white leukoplakic lesion. Excisional biopsy showed Langerhans cell histiocytosis. Positron emission tomography scanning revealed no lesions beyond this site. Native Langerhans cells are known to exist in the conjunctiva, yet only a few cases in the literature have described Langerhans cell histiocytosis of the conjunctiva, mostly in children. Conjunctival Langerhans cell histiocytosis has rarely been reported in an adult as leukoplakia. The authors advocate excisional biopsy for palpebral conjunctival Langerhans cell histiocytosis in older patients if the morbidity of closure is minimal, in addition to surveillance for multifocal disease.

Thyroid Eye Disease Following COVID-19 Vaccine in a Patient With a History Graves' Disease: A Case Report.

A 50-year-old woman with a history of controlled Graves' disease without clinical ophthalmopathy presents with 2 months of left more than right periorbital swelling and proptosis. Her eye symptoms and signs began 3 days following her second vaccination against the COVID-19 virus. Orbital imaging, elevated thyroid stimulating immunoglobulin, and negative systemic work up for other diseases were consistent with a diagnosis of active thyroid eye disease. The temporal relationship to her vaccination was likely consistent with autoimmune/inflammatory syndrome associated with adjuvants. Clinicians should remind patients of the symptoms and signs of thyroid eye disease and to seek appropriate medical and ophthalmic advice if they occur after the COVID-19 vaccine.

Stenotrophomonas maltophilia-Associated Dacryocystitis in Leukemia-Infiltrated Lacrimal Sacs: Case and Review of Literature.

A 91-year-old female with a history of chronic lymphocytic leukemia developed recurrent bouts of bilateral dacryocystitis. She underwent incision and drainage of the lacrimal sac with culture demonstrating the rare bacteria Stenotrophomonas maltophilia. She underwent subsequent dacryocystectomy with biopsy revealing bilateral involvement of chronic lymphocytic leukemia in the lacrimal sac. Stenotrophomonas maltophilia has been associated with immune suppression and is rarely seen in dacryocystitis. Local and/or systemic immune deregulation or suppression may play a role in lacrimal sac infection with this bacterium in some patients.

Necrotizing Granulomatous Dacryoadenitis With Non-Necrotizing Granulomatous Scar Hypertrophy: Two Histological Variants of Sarcoidosis in the Same Patient.

Orbital involvement with histologic necrosis is a rare manifestation of systemic sarcoidosis. The authors present a case of necrotizing dacryoadenitis in addition to non-necrotizing granulomas in a hypertrophic scar that is consistent with a diagnosis of sarcoidosis. A 60-year-old female presented with 2 months of painless right upper eyelid fullness and ptosis. CT imaging demonstrated right greater than left lacrimal gland enlargement. A biopsy demonstrated necrotizing granulomatous inflammation of the lacrimal gland. Additional workup was negative for infectious or lymphoproliferative disease. On further investigation, the patient noted thickening of a longstanding abdominal scar, and a subsequent punch biopsy of the scar demonstrated non-necrotizing granulomas suggestive of scar sarcoidosis. CT chest identified mediastinal lymphadenopathy. A diagnosis of sarcoidosis was determined. The authors thereby present an unusual case of 2 histologic variants of sarcoidosis presenting with necrotizing granulomatous dacryoadenitis and non-necrotizing scar granulomas.

External levator resection for involutional ptosis: is intraoperative suture adjustment necessary for good outcomes?

Purpose: To directly compare an algorithmic external levator resection technique with the choice of intraoperative adjustment to the same technique without intraoperative adjustments. Methods: A sequential controlled prospective comparative cohort study. Two cohorts were compared: a historical control adjustment, and an experimental non-adjustment group. Fourteen patients, 25 eyelids, were in the historical cohort; and 15 patients, 23 eyelids, were in the non-adjustment cohort. Primary acquired ptosis patients who met inclusion criteria were considered. All patients underwent a standardized external levator resection technique. Intraoperative adjustments were performed only in the historical cohort. Age, follow-up time, surgical time, and marginal reflex distance 1 (MRD1) were collected. Statistical analysis was performed using the Mann-Whitney U test. Statistical significance was p < 0.05. Primary and secondary outcome measures were postoperative MRD1 minus goal MRD1, and surgical time, respectively. Results: Twenty-five historical eyelids were compared with 23 non-adjusted eyelids. The average patient age was 68.4 years (range 19-84) and 59.3 years (range 24-83) for the adjusted and non-adjusted groups. Six-month postoperative (postoperative minus goal) MRD1 was -0.1 mm (95% CI -0.3-0.1) and -0.2 mm (95% -0.5-0.0) (p = 0.33), and surgical time was 13.8 min (95% CI 12.6-15.1) and 9.5 min (95% CI 9.0-10.1) (p < 0.001) for the adjusted and non-adjusted cohort, respectively. Conclusions: The external levator resection, utilizing a standardized algorithm approach, is an efficacious technique for involutional eyelid ptosis. With sound technique, this method can be performed without the need for intraoperative adjustment, thereby saving operative time and achieving similar results.

Management of postoperative pain in ophthalmic plastic surgery: a major review.

PURPOSE: Clinicians are becoming increasingly aware of the risks of opioid analgesics, and, consequently, are searching for alternatives to these agents. This review considers the existing literature regarding the management of pain after ophthalmic plastic surgery. METHODS: A literature search was performed through the PubMed database. Articles were assessed for relevance, and the appropriate data was extracted from the medical literature regarding pain management strategies after oculoplastic procedures. RESULTS: An emerging body of literature suggests the efficacy of a variety of non-narcotic agents in post-operative pain management. Many of these medications prevent the development of pain, and several have been studied in randomized trials. Specifically, pregabalin, ketorolac, acetaminophen, memantine, local anesthetics, and alternative therapies all have documented benefit in this setting. CONCLUSIONS: Several medications may prevent and treat pain after ophthalmic plastic surgery. These agents are well-tolerated, and many decrease the requirement for opioid analgesics. Clinicians should be aware of these therapies when considering non-narcotic pain management.

Odontogenic Abscess With Orbital Extension Through the Inferior Orbital Fissure Treated With Bony Decompression.

A 49-year-old otherwise healthy male presented with an odontogenic abscess and mild left facial swelling. CT imaging revealed gaseous hypodensities within the inferior orbital fissure and pterygopalatine fossa in addition to infection of the left masseter and temporalis muscle. Despite dental drainage, this rapidly progressed to orbital cellulitis with temporalis muscles abscess leading to compartment syndrome and globe tenting. He had an excellent outcome after canthotomy and cantholysis, urgent endoscopic and transconjunctival orbital decompression, temporalis muscle abscess drainage, and intravenous antibiotics. This case describes the use of bony orbital decompression for orbital compartment syndrome and globe tenting from odontogenic orbital cellulitis. In addition, this case radiographically demonstrates a transinferior orbital fissure passageway of an odontogenic abscess in the orbit.

Lacrimal Gland Orbital Lobe Cysts Associated With Lymphoid Hyperplasia or Mucosa-Associated Lymphoid Tissue Lymphoma in Patients With Chronic Autoimmune Disease.

Large cysts in the orbital lobe of the lacrimal gland are rare and are associated with Sjögren syndrome and B-cell mucosa-associated lymphoid tissue lymphoma. The authors describe 4 new cases of large orbital lobe lacrimal gland cysts. The first 2 patients, both with Sjögren syndrome, had unilateral cysts associated with chronic inflammation. Mucosa-associated lymphoid tissue lymphoma was also identified in the cyst wall of the second case and could not be completely excluded in the first case. The third patient, with a history of rheumatoid arthritis, had bilateral cysts, again associated with mucosa-associated lymphoid tissue lymphoma. The fourth patient, with no history of systemic disease, had a unilateral cyst associated with reactive lymphoid hyperplasia. Finally, the authors report the long-term outcomes of 3 previously reported cases.

Blepharoplasty Effect on a Described Algorithmic Approach to External Ptosis Repair: Is It Time for Unbundling?

PURPOSE: To investigate the effects of performing a previously described algorithmic levator resection for involutional ptosis with a blepharoplasty instead of through a small incision. METHODS: Eyelids with involutional ptosis and normal levator function were included in the study. An upper blepharoplasty was performed first. An external levator resection was then performed based on a described technique involving 2 mm resection of aponeurosis for 1 mm of desired lift, consistent tension on the aponeurosis between surgical cases, and standardized suture placement. RESULTS: Forty-one eyelids of 25 patients were included. Mean postoperative margin to reflex distance 1 (MRD1) was 2.98 mm, which was significantly higher than preoperative MRD1 (0.67 mm), but lower than the predetermined goal MRD1 (3.35 mm). Eight eyelids did not meet primary outcome of MRD1 within 1 mm of goal MRD1, with 5 undercorrections. There was no difference between the postoperative MRD1 compared with the same ptosis technique performed through a small incision only, but there were more intraoperative suture adjustments and fewer eyelids meeting the primary outcome when a concurrent blepharoplasty was performed. CONCLUSIONS: The addition of blepharoplasty with a previously described algorithmic approach external levator resection has an 80% success rate in achieving the primary outcome. When compared with a small-incision ptosis repair, concurrent blepharoplasty results in a less predictable outcome and an increased need for intraoperative adjustment. Performing an algorithmic technique for external levator resection with a blepharoplasty has less predictable outcomes, which raises the question of separating the procedures to improve patient care.

Biomechanics of the Levator Aponeurosis.

PURPOSE: To investigate biomechanical properties of the levator aponeurosis. METHODS: Patients undergoing external levator resection for primary or revision correction of acquired ptosis were analyzed as primary and revision groups. Immediately postoperatively, the resected segments of the levator aponeurosis were stressed by adding sequential masses to the tissue. Specimen length was recorded at each stress level. Stress-strain diagrams were used to summarize how the tissue elongated in response to the external forces, because these diagrams correct for differences in specimen size. Representative specimens were analyzed histologically. RESULTS: Twenty-two specimens from 14 patients in the primary group and 10 specimens from 7 patients in the revision group met inclusion criteria. In the primary group, the mean age was 66 years; 8 patients were women. In the revision group, the mean age was 69 years; 6 patients were women. Levator aponeurosis specimens in both the primary and revision group demonstrated proportional increases in length with increasing stress, demonstrating that the levator aponeurosis is extensile. Given the same amount of stress, the levator aponeurosis from primary specimens elongated more than revision specimens. Histologically, revision specimens exhibited increased collagen and haphazard, tangled elastin fibers. CONCLUSIONS: The levator aponeurosis obtained during surgical correction of acquired ptosis elongates in response to nominal external forces. This biomechanical property is important because the length of the aponeurosis may vary intraoperatively if variable forces are applied to the eyelid. This property might be related to connective tissue architecture and, specifically, fibrosis. Surgeons performing levator aponeurosis resection should be mindful to maintain a consistent amount of force on the levator aponeurosis when performing the resection to maximize intercase consistency.

Globe Loss From Intraocular Invasion of MIRAgel Scleral Buckle Components.

PURPOSE: To describe intraocular invasion of MIRAgel scleral buckles requiring evisceration. METHODS: This is an Institutional Review Board-approved retrospective consecutive case series of eyes requiring evisceration secondary to intraocular intrusion of MIRAgel implants performed at the Cole Eye Institute from 2000 to 2014. Charts were reviewed for age at surgery, gender, laterality, time between MIRAgel placement and evisceration, preoperative examination and imaging results, intraoperative findings, postoperative complications, and duration of follow up. RESULTS: Five eyes of 5 patients underwent evisceration due to a blind, painful eye secondary to MIRAgel expansion. The mean time between MIRAgel placement and evisceration was 21 years (range: 17-30 years). Preoperative ultrasound identified intraocular MIRAgel in 3 of 5 cases; however, intraocular MIRAgel was identified during surgery in all 5 cases. A transocular-approach orbitotomy was performed at the time of evisceration in an effort to remove the MIRAgel. Postoperative complications included ptosis and inability to retain an ocular prosthesis. No cases of orbital implant extrusion occurred. CONCLUSION: Scleral invasion and intraocular penetration of MIRAgel may occur decades after placement. This may result in a blind, painful eye requiring evisceration and orbitotomy to remove residual material. Suspicion of intraocular penetration of implant should be high in blind, painful eyes. Surgical removal can be difficult due to MIRAgel fragmentation. Conjunctival insufficiency may result in the need for further surgery after evisceration.

Frontalis Muscle Asymmetry and Lateral Landmarks.

PURPOSE: To investigate frontalis muscle asymmetry and characterize its lateral interdigitation with the orbicularis oculi muscle. METHODS: After making a mid-coronal incision and bluntly dissecting to the orbital rim, the frontalis muscle was exposed, marked, and photographed. The right and left muscle bellies were analyzed and compared in both pixels and cm ratios generated with NIH ImageJ software. A ratio of ≥1.5 was considered significantly asymmetric. The lateral interdigitation of the frontalis and orbicularis oculi muscles was measured from the supraorbital notch with a metric ruler. Data were analyzed using 2-sample t tests, paired t tests, log scales, and nonparametric tests were performed for sensitivity analyses. A p value of ≤0.05 was considered statistically significant. RESULTS: Fifty-eight hemifaces of 29 Caucasian cadavers were studied for muscle belly asymmetry. Thirty-six hemifaces of 18 Caucasian cadavers (9 males) were dissected for lateral landmarks and average age of these specimens was 73 years (range: 35-91 years). Significant asymmetry in muscle belly area was found in 6/29 (20%) specimens, with the right muscle belly larger in all 6 specimens. On average, the right muscle belly area was 1.23 times that of the left (p = <0.001). The average frontalis-orbicularis interdigitation occurred 3.4 cm lateral to the supraorbital notch. CONCLUSIONS: Significant frontalis muscle belly asymmetry exists in 20% of Caucasians cadavers. The right muscle belly was larger on average and in all cases of significant asymmetry. The frontalis muscle interdigitates with the orbicularis oculi on average 3.4 cm lateral to the supraorbital notch.

Sarcoid-like reaction in sentinel lymph node draining conjunctival melanoma.

A sarcoid-like reaction is the presence of noncaseating granulomas due to a T-cell mediated inflammatory reaction in draining lymph nodes of tumors or in the vicinity of tumors. Breast cancer, lymphoma, and cutaneous melanoma have been observed to induce a sarcoid-like reaction. Herein, a patient is reported with conjunctival melanoma in whom multiple noncaseating granulomas were observed in the sentinel lymph node without evidence of micrometastasis. Fungal and mycobacterium stainings were negative and further systemic workup excluded sarcoidosis. This case identifies conjunctival melanoma as a cause of a sarcoid-like reaction.

Anatomy and histology of the frontalis muscle.

PURPOSE: To determine the gross and histologic configurations of the medial and lateral frontalis muscle. METHODS: After making a midcoronal incision and bluntly dissecting to the orbital rim, the frontalis muscle was marked and measured. A protractor was used to measure the frontalis-orbicularis angle (FOA) and, when present, the angle of central bifurcation (AOB). Three strips of full-thickness forehead soft tissue measuring 0.5 cm × 8 cm were excised 3, 4.5, and 6 cm above the supraorbital notch and analyzed histologically for the presence of skeletal muscle fibers. Data were analyzed using 2-sample t tests, paired t tests, Pearson correlations, and mixed effect models. A p value of ≤ 0.05 was considered statistically significant. RESULTS: Sixty-four hemifaces of 32 cadavers (16 males) were dissected. All specimens were Caucasian. The average age was 78.2 years (range, 56-102 years). The average FOA was 88.7° (13.0°), and the average AOB was 90.0° (26.4°). A visible midline bifurcation occurred in 28 of 32 subjects (88%) at an average height of 4.7 cm (range, 2.4-7.2 cm) superior to the supraorbital notch. Continuous skeletal muscle fibers were present within the midline bifurcation histologically in 89%, 75%, and 11% of specimens 3.5, 5.0, and 6.5 cm above the supraorbital notch, respectively. In 46% of individuals, skeletal muscle fibers were continuously present microscopically within the gross bifurcation. CONCLUSION: While a medial frontalis muscle bifurcation occurs grossly in most senescent Caucasians, muscle fibers exist microscopically within this zone in nearly half of individuals.

Eyebrow Position Following Upper Blepharoplasty.

PURPOSE: To evaluate the effect of upper blepharoplasty on eyebrow height, accounting for ocular dominance, fat excision, change in MRD1, and degree of dermatochalasis. METHODS: Retrospective review of patients undergoing upper blepharoplasty between January 2013 and July 2014. Patients with a prior history of ocular trauma, disease, and surgery were excluded. Digital photographs were analyzed using NIH ImageJ software to measure pre and postoperative eyebrow height at the medial, central, and lateral positions, MRD1, and dermatochalasis. Univariable comparisons of brow height and MRD1 were performed. A multivariate analysis was used to assess for the effect of percentage change in MRD1 and dermatochalasis and of ocular dominance and fat excision in mean percentage change of eyebrow height. RESULTS: Charts of 19 patients were reviewed. Mean age was 73.2 years (SD = 8.86). There were 9 male (47.4%) and 10 female (52.6%) patients. There were 11 right eye dominant (57.9%) and 8 left eye dominant (42.1%) patients. Then 13 patients (68.4%) underwent fat removal. A univariable comparison found insufficient evidence to suggest a significant change from 0 postoperatively in brow height at all positions. A multivariable comparison found insufficient evidence to suggest MRD1, ocular dominance, or dermatochalasis were significantly associated with mean percentage change in brow height at all positions with or without fat excision. CONCLUSION: Upper blepharoplasty does not change eyebrow height at the medial, central, or lateral positions, after accounting for any impact of ocular dominance, fat excision, change in MRD1, or degree of dermatochalasis.