Silicone spacer repair of medial rectus after iatrogenic orbit fracture.

A 51-year-old woman underwent endoscopic nasal polypectomy and ethmoidectomy with accidental entry into the right orbit causing enophthalmos and transection of the medial rectus muscle (MR). The repair of a fracture and of a damaged MR is technically challenging, particularly when large portions of bone and muscle are missing. We report a rare case of repair of the bony defect with an implant and reattachment of the MR with a silicone retina band, through a combined transcaruncular and transconjunctival approach. Postoperatively, the patient had residual enophthalmos and strabismus; further surgical options are discussed.

Late-onset orbital hematoma secondary to alloplastic orbital implant mimicking transient ischemic attacks.

Alloplastic orbital implants are commonly used by surgeons in the repair of orbital wall defects. They are generally well tolerated, but they may cause late-onset complications. The authors present the case of a 65-year-old man with a history of left orbital floor fracture repair 25 years prior using a silicone orbital implant. He presented with a 1-year history of recurrent binocular vertical diplopia previously diagnosed as transient ischemic attacks. The patient subsequently presented with symptoms suggestive of orbital cellulitis, and after failure to respond to antibiotic therapy, he underwent surgical removal of the implant, revealing a large orbital hematoma. This case represents an unusual presentation of a known complication associated with orbital implant placement in a patient with previously diagnosed cerebrovascular disease as the cause of his neuroophthalmologic symptoms.

Periorbital physical urticaria in an anophthalmic patient with dermatographism.

Physical urticarias are a subset of chronic urticarias in which patients have urticaria induced by a variety of environmental stimuli, including pressure. A 50-year-old white woman with a history significant for dermatographism presented with recurrent swelling of the eyelids shortly after manipulation or removal of her custom-fit prosthesis. This swelling, which lasted for hours to days, responded to treatment with oral corticosteroids. This is an uncommon finding of a physical urticaria in the periorbital region.

Postoperative Candida Infection following Complex Periocular Reconstruction.

Postoperative candida infection is a rarely reported complication in cutaneous surgery, although it may develop more often in particular clinical settings. We present a 59-year-old woman with a well-controlled human immunodeficiency virus infection. She developed a bright red eruption with satellite pustules 2 weeks after excision of recurrent lentigo maligna melanoma of the left lower eyelid and periocular region. Due to defect size and complexity of the reconstruction (glabellar transposition flap, Hughes flap, composite graft from upper contralateral eyelid, and full-thickness skin graft from ipsilateral retroauricular region), she was placed on prophylactic oral amoxicillin-clavulanic acid and topical bacitracin and polymyxin. Immediate postoperative course was unremarkable, and sutures were removed after 7 days. Three days later, she developed bright red erythema and pustules within the surgical site and complained of burning. Empirically she was switched to topical gentamicin and oral ciprofloxacin, and later to linezolid, due to inadequate response. Wound culture grew Candida albicans sensitive to fluconazole and voriconazole. After oral fluconazole and topical clotrimazole initiation, the patient rapidly improved. The graft remained viable and apart from small partial dehiscence on the cheek, the healing was unremarkable. Apart from the case presentation, we also discuss different factors associated with postoperative candida infection, including immunocompromised status, surgical procedure location, and postoperative antibiotic use. Early recognition and treatment of postoperative candida infections are crucial to prevent delayed healing and associated morbidity.

Wegener granulomatosis causing compressive optic neuropathy in a child.

Wegener granulomatosis is an uncommon illness in children that is known to cause myriad ophthalmic complications, but it is rarely a cause of compressive optic neuropathy. A 17-year-old Hispanic boy with Wegener granulomatosis developed unilateral loss of vision, pain, and proptosis of the left eye. CT findings revealed enlargement of bilateral lacrimal glands with compression of the left optic nerve. The patient was admitted for high-dose intravenous corticosteroids and daily oral cyclophosphamide treatment. The patient's vision, pain, and proptosis improved dramatically, and he is now stable on mycophenolate mofetil and prednisone.

Group A streptococcal necrotizing fasciitis of the eyelids and face managed with debridement and adjunctive intravenous immunoglobulin.

The authors describe a patient with right upper and lower eyelid necrosis combined with facial, neck, and chest edema and sepsis secondary to Group A streptococcal infection after minor trauma. This is an uncommon, life-threatening condition that was successfully treated with limited surgical debridement, antimicrobial therapy, and intravenous immunoglobulin. Oculoplastic surgeons should be aware of the indications and potential benefit of adjunctive intravenous immunoglobulin therapy for Group A Streptococcus-induced necrotizing fasciitis.

Lacrimal gland involvement in graft-versus-host disease: a murine model.

PURPOSE: To describe lacrimal gland involvement in a murine model of acute graft-versus-host disease (GVHD). METHODS: Histopathologic examination was performed on lacrimal glands of mice affected by GVHD at 1, 2, 4, and 6 weeks after allogeneic bone marrow transplantation (BMT). Histopathologic scoring, based on characteristic GVHD findings in human disease involved evaluation of periductal inflammation, apoptosis, ductal stasis, ductal debris, and fibrosis. CD3, CD4, CD8, CD20, and CD68 antibodies were used to stain leukocyte subsets in GVHD lacrimal gland infiltrates. Lacrimal glands from syngeneic BMT mice were used in control experiments. RESULTS: Patchy periductal inflammation and focal fibrosis were significantly elevated as early as 2 weeks after allogeneic BMT. Histopathologic scoring of lacrimal glands after allogeneic BMT was significantly different at 4 (P = 0.005) and 6 (P < 0.0001) weeks when compared with scores in syngeneic control mice. The leukocytes in lacrimal gland GVHD infiltrates were predominately CD3+ T lymphocytes, most of which were CD8+, with fewer CD4+ cells present. CONCLUSIONS: This study describes the first murine model of lacrimal gland GVHD with features that closely mimic those described in human disease and indicates that lacrimal involvement occurs in acute GVHD.

Bilateral eyelid edema and orbital cellulitis associated with Pott's puffy tumor.

Pott's puffy tumor is rarely associated with orbital cellulitis. We describe a pediatric patient with Pott's puffy tumor and right-sided orbital cellulitis. He underwent urgent surgical drainage of a glabellar subperiosteal abscess and completed a six week course of intravenous antibiotics with complete resolution of infection and no long-term sequelae. Close monitoring with imaging for intracranial spread and multidisciplinary surgical intervention are commonly recommended.

Lacrimal sac melanoma.

A 48-year-old woman presented with a 5-month history of unilateral epiphora and progressive growth of a left-sided medial canthus mass. CT revealed a nonenhancing soft tissue mass of the left lacrimal sac with widening and erosion of the nasolacrimal canal. The tumor was resected and pathologically confirmed to be malignant melanoma. Despite wide resection and adjuvant radiotherapy, the patient developed metastases to the chest wall. The patient currently is receiving combined immunotherapy and chemotherapy. The clinical course and treatment strategies are reviewed for this highly aggressive and rare neoplasm.