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Purpose: To better define the wide spectrum of lax eyelid conditions, especially the subtype referred to as floppy eyelid syndrome, and to clarify its relationship with associated ophthalmic findings., Methods: A case-based retrospective review of all patients seen at UNC Department of Ophthalmology with a diagnosis of floppy eyelid syndrome or lax upper eyelid was performed. The period of review was from March 2002 to March 2007. A literature review was also performed using the term "floppy eyelid syndrome" and "lax eyelid syndrome" as the keywords in a PubMed search. Charts and cases were reviewed for the following information: age, sex, presence or absence of obesity, presence or absence of upper eyelid laxity, presence or absence of lower eyelid laxity, symmetry or asymmetry of eyelid laxity, sleeping position preference, diagnosis of obstructive sleep apnea (OSA), history of eye rubbing, diagnosis of keratoconus (KCN), lash ptosis, history of spontaneous eyelid eversion, papillary conjunctivitis, systemic hyperlaxity, diagnosis of meibomianitis, signs of anterior segment inflammation, and smoking or excessive sun exposure history., Results: From our UNC case review, 14 patients involving 17 eyelids were identified. From the literature review, 72 articles were recovered and evaluated to yield a total of 324 reported cases through February 2007. From the combined data (n = 338), the overall minimum prevalence of sleep apnea in patients with lax eyelid condition was 16% compared with an estimated 9% to 24% in the general population. Of patients with lax eyelid syndrome, those identified with OSA had significantly more individuals with obesity (76% vs. 20%) and male gender (89% vs. 61%) than the group without OSA. The prevalence of KCN in patients with lax eyelid syndrome was a minimum of 6.8%, which is considerably higher than the estimated prevalence in the general population of 0.6%. However, KCN appears to show a significant association with the patient's side of sleeping preference., Conclusions: Eyelid laxity can result from a number of involutional, local, and systemic diseases but is frequently of unknown etiology. When it is consistently associated with papillary conjunctivitis and dry eyes it can be referred to as lax eyelid syndrome (LES). A number of specific subsets of LES can be identified. One such subset, occurring primarily though not exclusively in males and associated with obesity, has been defined as the floppy eyelid syndrome (FES). OSA has been associated with FES where it occurs with greater frequency than in the general population, but no greater than seen in obese males without FES, and therefore appears to represent an epiphonomenom only. However, given the demographics of FES, this condition offers some predictive value for OSA and should alert the physician to evaluate the sleep habits of all such patients. Keratoconus also shows some association with FES and with LES. However, data suggest that the causative factors are sleep preference for the involved side and nocturnal eyelid eversion, rather than any underlying physiologic or anatomic relationship.

Purpose: To compare the rate of exposure in the immediate 3-month postoperative follow-up period with the rate of exposure after the immediate postoperative period in 419 anophthalmic patients with a bioceramic (aluminum oxide) orbital implant., Methods: This is a retrospective, clinical case series of 419 patients who received a bioceramic orbital implant. All patients who presented to five oculofacial surgeons (D.J., S.G., J.D., S.K., L.M.) from January 1, 2000, to June 1, 2007, who received a bioceramic orbital implant and had a minimum of 3 months of follow-up were included in this study. The authors analyzed age, gender, type of surgery, implant size, peg system, follow-up duration, time of pegging, and problems encountered. The data from the patients with greater than 3 months of follow-up with exposure of the bioceramic implant are detailed in this report., Results: There were 353 patients followed for 3 to 96 months with an average of 30 months of follow-up (median 23 months). Implant exposure occurred in 32/353 bioceramic implants (9.1%). Six of the 32 (19%) exposures occurred during the 90-day postoperative period (average 2.1 months). Twenty-six (81%) exposures occurred outside of the 90-day postoperative period (average 27.5 months, range 4-82 months)., Conclusions: Implant exposures can occur anytime postimplant placement. This review discovered an implant exposure rate of 9.1%, with the majority of the exposures occurring after the postoperative follow-up period. Patients with porous orbital implants should be followed on a long-term basis to detect this complication.

This case reports 4-year-old monozygotic twins incompletely concordant for simple congenital ptosis. Pedigree analysis demonstrates 4 generations of autosomal dominant transmission. The case and pedigree are reviewed in light of a number of recent advances in the understanding of genetic influences on simple congenital ptosis.

An 18-day-old child presented with rapid enlargement of a firm subcutaneous eyelid mass present since birth. Imaging revealed extension into the anterior orbit. Incisional biopsy revealed juvenile xanthogranuloma. Multidisciplinary systemic evaluation revealed no other lesions, although thrombocytopenia was discovered, prompting a bone marrow biopsy to rule out malignancy. Once none were uncovered, the thrombocytopenia was felt to be consistent with idiopathic thrombocytopenia. The patient was treated with intralesional steroid injections and concurrent oral prednisolone to normalize platelet count. The lesion softened, and reinjection 4 weeks later induced further regression, allowing the eyelid to clear the pupil. Although ocular involvement is a commonly reported extracutaneous manifestation of juvenile xanthogranuloma, a congenital subcutaneous eyelid lesion with orbital involvement has not been previously reported. Juvenile xanthogranuloma is typically benign and self-limiting; however, it can be associated with systemic disease, and treatment may be necessary to prevent amblyopia if the eyelid is involved. Early multidisciplinary evaluation for systemic lesions and associated malignant conditions should be considered.

Darier disease is a rare autosomal dominant skin disorder that infrequently has ocular manifestations. The authors describe 2 cases of patients with known Darier disease presenting with eyelid lesions resembling basal cell carcinomas. Biopsies demonstrated histopathologic changes consistent with Darier disease. To the authors' knowledge, this presentation has not been previously reported. Ophthalmologists and dermatologists should be aware of this type of presentation in Darier disease.

A 57-year-old woman presented with a recurrent lower eyelid growth that was found to be a striated muscle hamartoma on surgical biopsy. This is a rare entity in adults with no history of congenital abnormality. Several other rare, benign lesions may be clinically similar and should be considered in the differential diagnosis of an eyelid lesion containing striated muscle.

Mycobacterium chelonae is ubiquitous in the environment but is an uncommon cause of ocular and periocular infections. It is a pathogen that has been gaining increased attention in the ophthalmic literature because of the relatively large number of infections associated with laser-assisted in situ keratomileusis and other forms of refractive surgery. The authors present 3 patients who developed canaliculitis culture positive for M. chelonae more than a year after SmartPlug placement. These cases highlight some of the clinical scenarios that may be encountered in those who present with canaliculitis with a history of intracanalicular plug placement. Therapeutic considerations are also suggested.

Purpose: To describe the technique and results of double-bridged flap reconstruction of full-thickness upper eyelid defects that spares the upper eyelid margin., Methods: The surgical technique is described and illustrated in 2 patients who underwent this procedure., Results: The 2 patients presented in this study achieved excellent functional and cosmetic results following the procedure. One patient subsequently underwent a frontalis sling procedure to correct residual ptosis., Conclusions: Double-bridged flap reconstruction of the upper eyelid that spares the eyelid margin can provide excellent functional and cosmetic results, particularly in cases of nonmarginal eyelid tumor excision, severe upper eyelid scarring, and severe cicatricial retraction.

Since its introduction into clinical medicine in 1980, botulinum toxin has become a major therapeutic drug with applications valuable to many medical sub-specialties. Its use was spearheaded in ophthalmology where its potential applications have expanded to cover a broad range of visually related disorders. These include dystonic movement disorders, strabismus, nystagmus, headache syndromes such as migraine, lacrimal hypersecretion syndromes, eyelid retraction, spastic entropion, compressive optic neuropathy, and, more recently, periorbital aesthetic uses. Botulinum toxin is a potent neurotoxin that blocks the release of acetylcholine at the neuromuscular junction of cholinergic nerves. When used appropriately it will weaken the force of muscular contraction, or inhibit glandular secretion. Recovery occurs over 3 to 4 months from nerve terminal sprouting and regeneration of inactivated proteins necessary for degranualtion of acetylcholine vesicles. Complications are related to chemodenervation of adjacent muscle groups, injection technique, and immunological mechanisms.

We describe a rare intramuscular infiltrating lipomatous tumor affecting the superior oblique muscle. A 37-year-old female presented with eyelid swelling, proptosis and motility disturbance. Imaging studies revealed enlargement of the superior oblique muscle with a fat-density infiltrating lesion within its belly. The clinical and radiologic findings suggested a cystic or necrotic lesion. Biopsy showed an infiltrative tumor consisting of adipocytes with included degenerated muscle fibers. Histologic features were consistent with a benign intramuscular lipoma, rather than the more aggressive well-differentiated liposarcoma. A review of the literature found three previously described periorbital cases, two in the eyelid, and one in the anterior orbit. Lipomas are common tumors that usually do not cause functional impairment but are very rare in the orbit. Intramuscular lipoma is a rare subtype that can result in significant morbidity. Enlargement of an extraocular or periorbital muscle with a low-density infiltrating lesion should raise suspicion for this unusual tumor.

Purpose: A small percentage of cases with essential blepharospasm or hemifacial spasm will become resistant to botulinum toxin A (Botox). We present our experience treating these patients with botulinum toxin B (Myobloc)., Methods: We reviewed all charts of patients in one physician's practice who received botulinum toxin B after becoming refractory to botulinum toxin A. For each treatment session, patients were evaluated for side effects, relief of spasms, and duration of treatment effect., Results: Data were collected on 16 patients and a total of 93 treatment visits. Average total dosage was 3,633 U per treatment session. Mean duration of beneficial effect was 7.3 weeks and was most commonly rated as fair to excellent. Side effects for botulinum toxin B occurred at a higher rate than is typical for botulinum toxin A. Most common side effects were pain on injection (100%), ptosis (32.3%), facial or mouth droop (22.6%), dry mouth (17.2%), dry eye (9.7%), exposure keratitis (7.5%), and blurred vision (5.4%). The rate of occurrence of side effects appears to be dose-dependent., Conclusions: Botulinum toxin B is a useful treatment for cases that have become refractory to botulinum toxin A. The duration of beneficial effect is shorter than for type A. The side effect profile is similar to that for toxin type A except for pain on injection and the occurrence of dry mouth. Side effects occurred at a higher frequency than with botulinum toxin A, and the pattern suggests that botulinum toxin B spreads more diffusely. Side effects appear to be dosage-related.

A 22-year-old man with a recurrent intraconal cystic mass of the orbit presented with proptosis, motility restriction, and optic disc edema. On initial surgery, the cyst wall showed nonkeratinized cuboidal epithelium with adnexal structures. After recurrence, repeat histopathologic evaluation again showed nonkeratinizing conjunctival epithelium with goblet cells. The diagnosis was consistent with a dermoid cyst of conjunctival origin. Our review of the literature found 29 previous cases in the literature. Unlike typical cutaneous dermoids, conjunctival dermoids occur in young adults and are usually located in the nasal or superonasal deep orbit. The location and adnexal structures associated with these lesions suggests derivation from embryonic epithelium destined to become caruncle.

A 2-year-old child presented with a painless subperiosteal periorbital mass of 6 months' duration. This was associated with several small cutaneous nodules that resolved spontaneously before surgical excision of the orbital lesion. Excisional biopsy of the lesion revealed a deep granuloma annulare in a subperiosteal location along the superior orbital rim. The patient did well after surgery, with no evidence of recurrence after 18 months. Deep granuloma annulare is a rare lesion often confused with rheumatoid nodule. It has not previously been reported in a subperiosteal location around the orbit. Although granuloma annulare is typically benign and often self-limiting, in some cases it can be associated with systemic disease.

Lymphangioma is a benign nonencapsulated orbital tumor that is difficult to treat. Recently, systemic corticosteroids were advocated as a safe and effective alternative to surgical drainage of the cysts. We describe our experience with 3 cases in which proptosis progressed or did not improve despite the exclusive use of systemic steroids for 1 week, necessitating urgent surgical intervention. These three cases demonstrate that at least in some cases, steroids alone may be ineffective, and alternative interventions must be undertaken.

Purpose: To determine the feasibility of the use of flaps from the capsule surrounding porous polyethylene implants in repairing large or recurrent implant exposures., Design: Retrospective, noncomparative, interventional case series., Participants: Sixteen patients with exposed porous polyethylene implants., Methods: Vertical and horizontal flaps were created from the implant capsule. These flaps were used to create a double layer of closure to seal the exposure. All patients had a minimum follow-up of at least 12 months., Main Outcome Measures: Repair of the exposure without recurrence during the follow-up interval, and assessment of complications., Results: At the last follow-up visit, the socket was completely healed in all but 2 patients. In 1 of them, the implant was subsequently exchanged. Other complications included motility loss, conjunctival cyst, and granuloma formation., Conclusions: The use of the implant capsule to salvage exposed porous polyethylene implants is an effective technique; it is associated with some complications that can be minimized by careful case selection.

Purpose: To determine the efficacy of primary placement of a motility coupling post (MCP) in evisceration with the porous polyethylene (PP) implant., Design: Retrospective noncomparative, interventional case series., Participants: Twenty patients undergoing evisceration., Methods: A modified evisceration technique with porous polyethylene implants was performed, in which an MCP was placed primarily during the initial surgery. All patients were observed postoperatively for a minimum of 3 months., Main Outcome Measures: Socket motility, final position of the MCP in the orbit, patient satisfaction., Results: At the last follow-up visit, an acceptable range of motility was attained in all patients. Nineteen patients had a centrally positioned MCP, and all patients were pleased with the cosmetic outcome and the range of motility achieved. Minor complications were noted, including a malpositioned MCP (n = 1) and poor motility in upgaze (n = 8)., Conclusions: Primary peg placement at the time of evisceration with the PP implant is a promising technique with relatively minor complications so far, but properly constructed studies are required prospectively to compare motility with the MCP versus nonpegged implants.

Epibulbar osseous choristoma is a choristomatous lesion of the conjunctiva containing bone. Originally called epibulbar osteoma, this lesion was first described by von Graefe in 1863. We discuss a case of a 4-year-old patient who presented with an epibulbar lesion consistent histopathologically with an epibulbar osseous choristoma, and report a review of the literature. The differential diagnosis of osseous choristoma should include classical limbal dermoids, epithelial inclusion cysts, prolapsed orbital fat, papillomas, dermolipomas, and complex choristomas. Although the rarest of epibulbar choristomas, 51 epibulbar osteomas have now been reported in the medical literature. Most commonly, this variety of choristoma presents as an isolated epibulbar lesion within the supratemporal quadrant but may occur in other locations on the surface of the globe and possibly in conjunction with other choristomatous tissue as much as 10% of the time. Frequently, they may involve the muscle or have dense attachments to the underlying sclera. Osseous choristomas most likely represent congenital lesions with a potential for slow growth but may occur in association with trauma. Options for management include observation or surgical excision. When surgery is contemplated, preoperative radiographic imaging may be helpful for assessing adhesion to the sclera or extraocular muscles.

Purpose: To compare the rate of fibrovascularization of wrapped versus unwrapped hydroxyapatite (HA) spheres in an animal model and to investigate how drilling small-diameter access holes at the time of implantation affects the rate of fibrovascular ingrowth in wrapped implants., Methods: The right eyes of 20 New Zealand White rabbits were removed and a 12-mm HA sphere was implanted in each socket. The spheres were left bare in 8 of the animals. In the other 12, the implant was wrapped in an autologous sclera shell. In 4 animals from each group, a 1-mm diameter access hole was drilled into the spherical center of the implant at the sites of extraocular muscle insertion and at the posterior pole before implantation. All implants were explanted after 1 week., Results: The mean depth of fibrovascularization in the bare group without access holes (n = 4) was 100% (SD = 0). The mean depth of fibrovascularization in the wrapped group without access holes (n = 8) was 30.1% (SD = 11.0). The difference between these two groups was statistically significant (P<0.001). The mean depth of fibrovascularization in the wrapped group with access holes (n = 4) was 91.5% (SD = 9.8). Compared with the wrapped group without access holes, the difference was statistically significant (P<0.001). The difference in the mean depth of fibrovascularization between the bare group without access holes and the wrapped group with access holes failed to reach statistical significance (P = 0.18)., Conclusions: On the basis of this preliminary study, we conclude that whereas scleral wrapping does significantly slow the rate of fibrovascular ingrowth, the concomitant placement of access holes greatly improves the rate of fibrovascularization.

Purpose: To describe the anatomic and histologic relations of the muscle of Riolan in the eyelid margin., Methods: Serial microscopic sections of the eyelid were prepared, digitally scanned, and then reconstructed with computer software to create a 3-dimensional profile of this muscle group in two planes., Results: The muscle of Riolan is a distinct subdivision of striated muscle that is separate from the pretarsal orbicularis muscle. In parasagittal eyelid sections, the muscle appears to be composed of two separate bundles, the pars ciliaris, located anterior to the tarsal plate, and a second smaller bundle, the pars subtarsalis, located posterior to the orifices of the meibomian glands. Coronal sections, however, demonstrate numerous muscle fibers that traverse the tarsus, connecting the two muscle groups that we describe for the first time as the pars fascicularis., Conclusions: The three muscle subdivisions are therefore physically joined together and appear to act as a single functional entity that should be collectively referred to as the muscle of Riolan.

Surgeons must decide on the type of anesthesia to use when performing cataract surgery. These "viewpoints" articles provide a well-balanced discussion offering the pros and cons of both topical anesthesia and retrobulbar/peribulbar injection. Dr. Dutton gives an overview of both techniques, focusing on relevant orbital anatomy. Drs. Hassan, Edelhauser and Kim, review the various types of topical anesthesia currently in use, and Drs. Spriggs and Broocker examine retrobulbar and peribulbar injections. Both techniques are associated with advantages and risks, so each surgeon must decide which technique is best suited for his or her own practice.

Purpose: We report the use of bovine pericardium as an alternative wrapping for porous orbital implants after enucleation., Methods: We retrospectively reviewed the records of all patients who received a bovine pericardium-wrapped orbital implant after enucleation by the authors between August 1, 1996, and December 1, 1999., Results: Eighty patients underwent placement of bovine pericardium-wrapped orbital implants. The average age at the time of implantation was 49.3 years (range, 5 years to 83 years). The mean follow-up interval was 11.8 months (range, 2 to 41 months). There were no intraoperative complications. No patient had secondary systemic infection or showed evidence of rejection. There was no clinical evidence to suggest that vascularization of the porous implant was unusually delayed, and there were no complications after secondary drilling and placement of a coupling post. Four (5%) of 80 patients had complications requiring removal of the spherical implant. All 4 patients had hydroxyapatite implants. Two patients had significant exposure requiring removal of the implant at 2 months after surgery; 1 patient had a chronic fistulous tract with secondary infection 3 years after surgery: and 1 patient had chronic orbital pain requiring removal of the implant at 1 year after surgery., Conclusions: The incidence of implant exposure was less than 4%. This compares favorably to the incidence of exposure of 9% to 21% reported in recent literature. Other complications were few and of minimal clinical significance. The authors conclude that bovine pericardium is a viable option to sclera as a wrapping for porous orbital implants.

Purpose: To report the onset of malignant peripheral nerve sheath tumor of the orbit 8 years after irradiation in a patient with neurofibromatosis type-1., Methods: Case report of a young man with neurofibromatosis type-1 who received irradiation for presumed bilateral optic nerve and chiasmal gliomas and in whom a malignant peripheral nerve sheath tumor later developed. Exenteration with extirpation of the entire contents of the orbit was performed 6 times., Results: Complete recurrence of the tumor occurred after each surgical procedure until the patient died of malignancy., Conclusions: Our case underscores the risk of irradiation, especially in children with neurofibromatosis type-1, and emphasizes that radiotherapy should never be given as an empirical therapy. The authors believe that irradiation and neurofibromatosis type-1 may, in combination, pose a significant risk for the development of malignancies. Clear-cut indications and a precise tissue diagnosis are desirable before the initiation of radiotherapy, particularly in the pediatric population. We recommend that if irradiation is necessary in persons with neurofibromatosis type-1, regular follow-up is imperative. In view of the hostile nature of malignant peripheral nerve sheath tumor, early aggressive treatment appears to be the only viable alternative at present.

We describe a case of focal argyrosis of the conjunctiva clinically simulating a melanoma. An 82-year-old woman was referred for an asymptomatic pigmented conjunctival lesion. Her only significant past ocular history was strabismus surgery 76 years earlier. Biopsy of the conjunctiva and lateral rectus muscle revealed the discoloration was pigment granules. Energy-dispersive x-ray microanalysis revealed the pigmentation to be silver deposits. The patient had strabismus surgery probably using a silver clip. Argyrosis should be considered in the differential diagnosis of focal pigmented conjunctival lesions.

Purpose: Ewing's tumor is a primary tumor of bone in childhood that only rarely involves the orbit. Most such cases are metastatic from distant sites. This tumor may be confused with other small round cell malignancies of childhood, and immunohistochemical studies are essential in making the diagnosis., Methods: We present two cases of Ewing's tumor of the orbit. One was in a 22-year-old boy with an occult primary tumor in the frontal bone that became symptomatic after forehead trauma. The other example was in a 7-year-old boy with a known Ewing's primary of the clavicle. The clinical manifestations and diagnostic criteria are discussed., Results: In most cases with orbital involvement, ophthalmic symptoms consist of proptosis, pain, and occasionally visual loss and motility restriction. The diagnosis is typically unsuspected before histologic evaluation. Electron microscopic and immunohistochemical analyses are essential in making the diagnosis and are necessary for all such small round cell tumors., Conclusions: Ewing's sarcoma is a rare orbital tumor of bone mainly affecting children. Local treatment relying on surgical extirpation and radiotherapy alone has proven inadequate, with 5-year survival rates of <10%. The addition of chemotherapy has improved survival rates significantly to approximately 50%.

Purpose: To determine the effectiveness of using a radiofrequency instrument to resect a V-shaped tarsal wedge for the correction of cicatricial upper eyelid entropion., Methods: Prospective evaluation of 16 upper eyelids of 11 consecutive patients., Results: The operation was successful in all 16 eyelids, with excellent cosmetic and functional outcomes., Conclusions: Tarsal V-wedge resection is an effective alternative to other complicated techniques in the management of upper eyelid cicatricial entropion.

Purpose: To compare bovine pericardium (Periguard; Bio-Vascular, Inc., St. Paul, MN, U.S.A.) and homologous sclera as spacer graft analogs in a rabbit model., Methods: A nonrandomized experimental animal study was conducted. Elliptical subconjunctival implants were placed in one lower eyelid each of 10 rabbits. Five rabbits received homologous sclera implants, and five received bovine pericardium implants. The rabbits were killed 7 weeks later, and the lower eyelids were examined clinically and histopathologically., Results: Rabbit eyelids implanted with Periguard had a more marked inflammatory reaction and more significant collagen lamellar disruption than eyelids implanted with homologous sclera, although clinically they appeared quite similar., Conclusions: Although bovine pericardium elicited a more intense inflammatory response at the histopathologic level, both implants were similarly tolerated at the clinical level. These findings are consistent with animal and human investigations of bovine pericardium in other parts of the body, and warrant further studies into its potential use in the human eyelid.

Purpose: To evaluate the success of internal eyelash bulb extirpation in the management of trichiasis., Methods: The procedure was performed on 26 consecutive eyelids., Results: Our technique was successful in all cases, with no recurrence of signs or symptoms., Conclusions: Internal eyelash bulb extirpation is a safe and effective technique to remove trichiatic lashes, while avoiding injury to the conjunctiva.

Purpose: Lack of adequate fibrovascular ingrowth has been implicated as a cause of exposure of hydroxyapatite (HA) implants in anophthalmic sockets. We investigated the vasculopathic effects of external beam irradiation, and the fibrovascular-enhancement effects of hyperbaric oxygen (HBO), on HA implant exposure and fibrovascular ingrowth in a rabbit model., Methods: Eighteen rabbits underwent enucleation with implantation of a 12-mm HA sphere. Six rabbits received 20 Gy of external beam orbital irradiation prior to enucleation. Three irradiated and 6 nonirradiated rabbits received postoperative HBO. Three weeks postoperatively, all rabbits were evaluated clinically for evidence of implant exposure. Implants were then removed, and histopathologic analysis of fibrovascular ingrowth was performed., Results: The amount of vascularization as measured by the depth of ingrowth was greater for nonirradiated (89% ingrowth) than for irradiated (71% ingrowth) animals. HA implant exposure occurred in 1 of 12 (8%) of the nonirradiated, and 4 of 6 (67%) of the irradiated rabbit orbits. HBO did not protect irradiated rabbits from exposure, but did enhance fibrovascular ingrowth in nonirradiated rabbits (100% ingrowth vs. 77% ingrowth)., Conclusion: Impaired orbital vascularization from prior irradiation appears to retard fibrovascular ingrowth into HA implants, and is associated with an increased incidence of exposure. While HBO did not diminish the likelihood of exposure in irradiated sockets, HA fibrovascular ingrowth in normal orbits appeared to increase with HBO. This may have beneficial clinical application in cases of exposure in nonirradiated orbits.

Purpose: We compared bovine pericardium and homologous sclera as wrapping materials for hydroxyapatite (HA) ocular implants in enucleated New Zealand white rabbits., Methods: Eighteen rabbits were unilaterally enucleated and the sockets implanted with 10-mm HA spherical implants. Six implants were wrapped with homologous sclera, 6 with bovine pericardium, and 6 were not wrapped. The rabbits were killed 7 weeks later and the sockets were examined clinically for inflammation and implant exposure. Exenterated specimens were assessed histopathologically for inflammation and vascularization., Results: No clinical evidence of implant exposure or extrusion was detected in rabbits receiving sclera or bovine pericardium wrapped implants. Histopathologically, the bovine pericardium displayed more inflammation in its outer portion, as well as more disruption of its lamellar arrangement than did the sclera. Fibrovascular in-growth was complete in all wrapped implants., Conclusion: Bovine pericardium behaves similar clinically to homologous sclera as a wrapping material for spherical HA ocular implants in a rabbit model, and may represent a reasonable alternative to sclera in such procedures in humans.

Purpose: The treatment of the traumatic contracted anophthalmic socket is challenging. The ability to wear an ocular prosthesis may require multiple operations to replace orbital volume, mucosa, or both. Hard palate mucosal grafts are a logical choice to augment mucosa and volume in the reconstruction of a contracted socket., Methods: Ten patients with severely contracted sockets underwent socket reconstruction using hard palate mucosal grafts. The mucosal surface lining the contracted sockets was undermined and recessed toward the lid margins. Hard palate mucosal grafts that were harvested freehand and by using a radiofrequency instrument were placed in the socket fundus and sutured to the recessed mucosal edges. Forniceal sutures were placed full thickness through the lids, and custom conformers were placed in the sockets. In six patients, fixation sutures were passed through the conformer, fornices, and full thickness through the lid. In four patients, temporary tarsorrhaphies were placed for a minimum of 4 weeks postoperatively., Results: Postoperatively, 8 of the 10 patients were able to wear an ocular prosthesis comfortably. Cosmesis was acceptable. Two patients had recurrent socket contracture and were unable to wear a prosthesis., Conclusions: Hard palate mucosal grafts are a useful option in the surgical rehabilitation of contracted sockets. A mucosal surface, resistance to contracture, ease of harvesting, and ability for additional harvesting are advantages over other graft materials.

Hemorrhagic cyst formation may occur within months or years following repair of orbital fractures with alloplastic materials. Patients present with a sensation of pressure in the involved orbit, double vision, and globe displacement. Evaluation must rule out infectious, inflammatory, and vascular etiologies. Computerized tomography scans reveal a soft tissue density surrounding the alloplastic implant. Drainage of the cyst and fibrous capsule, with excision of the capsule and removal of the alloplastic implant, is curative. This article presents three clinical cases, highlighting the evaluation and management of this postsurgical development. Use of the protocol described resulted in complete resolution of all clinical symptoms, and the CT scans were normal. As these materials will continue to be utilized, surgeons should be aware of this potential delayed complication and its management.

Background: The effect of thyroid orbitopathy on intraocular pressure (IOP) remains controversial. We carried out a study to determine the effect of orbital decompression surgery on the IOP in patients with advanced thyroid orbitopathy., Methods: The records of 12 consecutive patients (22 eyes) who underwent decompression surgery for severe thyroid orbitopathy between 1985 and 1996 were reviewed. All patients were maintained on essentially the same medications before and after surgery. The IOP readings, obtained by means of applanation tonometry in primary gaze, from the pre- and postoperative visits were recorded, and the net change was calculated., Results: The mean preoperative and postoperative IOP values were 19.8 mm Hg and 16.8 mm Hg respectively, a significant difference (p = 0.008). Seven of eight eyes with an IOP of 21 mm Hg or greater preoperatively had a postoperative IOP less than 21 mm Hg; these eyes showed a mean decrease in IOP of 5.6 mm Hg. The degree of preoperative IOP elevation was found to be a strong predictor of the amount of IOP lowering after surgery (p = 0.014)., Interpretation: Our results support the concept that orbital congestion associated with thyroid orbitopathy produces an increase in IOP by elevation of episcleral venous pressure (EVP) and that orbital decompression may reduce the IOP by decreasing EVP. Decompression surgery may obviate the need for more aggressive management of glaucoma in patients with severe thyroid orbitopathy.

Background: Second primary malignancies are common after bilateral retinoblastoma; their estimated incidence has been as high as 51% 50 years after diagnosis. Fifteen patients who developed sebaceous gland carcinoma after radiation therapy have been reported in the literature, five of whom were treated for bilateral retinoblastoma., Methods: The authors conducted a retrospective chart review of patients treated for bilateral retinoblastoma at Duke University Medical Center who later developed sebaceous gland carcinoma., Results: This article reports two patients who developed sebaceous gland carcinoma after radiation therapy for bilateral retinoblastoma., Conclusions: Delay in diagnosis is often associated with sebaceous gland carcinoma. Because high mortality is observed with metastatic disease, the recognition of this association is important for anyone who follows patients with a history of bilateral retinoblastoma or prior cranial radiation therapy.

A computerized topographic analysis system (EyeSys [EyeSys Technologies, Houston, TX, U.S.A.]) was used to evaluate corneal astigmatic changes (central corneal power and astigmatic axis) after blepharoptosis surgery on 29 eyelids (22 patients). Fifteen nonoperated eyelids of study patients undergoing unilateral ptosis repair were used as controls. All patients were evaluated preoperatively and again 6 weeks after surgery. Fifteen operated eyelids and five controls were also examined 12 months after surgery to evaluate the stability of these measurements. In 72.4% of operated eyes, corneal topography demonstrated increased with-the-rule astigmatism 6 weeks after surgery, 13.8% of surgical eyes showed increasing against-the-rule astigmatism, and in 13.8%, no change was noted from preoperative measurements. None of the 15 control eyes demonstrated any change in corneal astigmatic axis or significant change in central corneal power. By 12 months after surgery, all of the operated eyes showed a regression toward the amount and pattern of preoperative astigmatism. Only two of 15 eyes maintained a difference of > 0.3 D of central corneal power greater than their preoperative measurement at 1 year. These data suggest that corneal topography may be altered by changes in eyelid position, although the changes appear to be temporary in most patients.

Multicentric melanomas in the same eye are rare, with few cases substantiated by histology and serial sectioning. We report a patient with two documented choroidal malignant melanomas in one eye. The initial tumor spontaneously decreased in size for over 2 years before a second tumor appeared in a noncontiguous location in the same eye. After enucleation, serial sections showed that the two lesions were independent choroidal melanomas. We review the literature regarding multiple, independent intraocular choroidal malignant melanomas.

Several authors have reported significant exposure rates using the hydroxyapatite orbital implant in the treatment of the anophthalmic socket. Histologic studies by ourselves and others have suggested that lack of fibrovascular ingrowth into the implants may contribute to conjunctival breakdown and exposure. Recently, much attention has been given to angiogenic factors, such as rTGF-beta 2 and those found in plasma, in accelerating wound healing and fibrovascular ingrowth. This pilot study compares the rate of vascularization of hydroxyapatite orbital implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution with that in untreated controls ina population of New Zealand albino rabbits. Hydroxyapatite orbital spheres were implanted subcutaneously and in enucleated orbits. Untreated implants were used as a control. Implants pretreated with plasma, rTGF-beta 2, and a saline/gentamicin solution were removed and examined histologically at weekly intervals for the first 3 weeks after implantation. Histologic studies demonstrated that the rate of vascularization significantly increased between 2 and 3 weeks postoperatively in all study groups. Pretreating the implants with rTGF-beta 2 in phosphate buffered solution (PBS) or autogenous plasma did not significantly increase the rate of vascularization in comparison with controls at weeks 1 and 2. However, pretreating the implants with a saline/gentamicin solution or PBS alone was associated with an increased rate of vascularization at weeks 2 and 3. No statistically significant difference in vascularization was noted between the subcutaneous and orbital implants at any week. Hydroxyapatite implants pretreated with saline/gentamicin or phosphate buffered solutions underwent more rapid vascularization at weeks 2 and 3 in comparison with controls. Additionally, all groups were noted to have a more rapid rate of ingrowth between weeks 2 and 3 than between weeks 1 and 2. Plasma and rTGF-beta 2 (at the dose used) did not significantly alter the rate of vascularization of hydroxyapatite implants during the first 2 to 3 weeks. The significance of these findings is discussed.

Purpose: This study was to determine whether age-related decrements in type I collagen synthesis occur in human eyelid skin., Methods: Using an antibody to procollagen I, we investigated collagen synthetic activity in skin removed for cosmetic purposes from 10 white patients between the ages of 4 and 77 years. Eleven masked referees graded the immunostaining on a scale of 1 (most intense) to 10 (least intense)., Results: The multiple range test for rank by group demonstrated more intense staining in younger patients compared with older patients. An average correlation coefficient of 0.8432 (p < 0.05) existed between each of the referee's rankings., Conclusion: Type I collagen synthesis diminishes with age in eyelid skin.

Purpose: To describe a patient with a deviated orbital implant after enucleation., Method: Case report., Result: We examined a postenucleation patient with a medially deviated ("esotropic") implant after peg drilling. Modification of the posterior surface of the prosthesis improved cosmesis in the primary position., Conclusions: During enucleation surgery, surgeons may use a spherical implant rather than modify the anterior face in patients with preexisting strabismus, with severe trauma to the extraocular muscles, or with risk of implant deviation. Additionally, secondary procedures may alter implant position. Occasionally, patients without obvious preoperative risk factors may have deviation of the modified face of the implant. Flattening the implant creates an asymmetric surface that may lead to a deviated orbital implant.

Background: The authors treated ten patients (13 eyelids) with visually significant blepharoptosis and compromised corneal protective mechanisms resulting from paresis of ocular motility and absent Bell phenomenon., Methods: Traditional upper eyelid surgery consisting of frontalis suspension (6 eyelids) or levator aponeurosis advancement (7 eyelids) was used. In all patients, the ptosis repair was combined with maximum recession of the lower eyelid, using a posterior lamellar scleral spacer graft. The goal was to maintain a narrow, vertical, interpalpebral fissure to allow for eyelid closure, but to reposition this opening centrally over the pupil., Results: Postoperatively, all patients achieved significant improvement in superior visual field, with no associated keratopathy. Complications were few, minor, and transient. The postoperative cosmetic appearance was acceptable in all patients., Conclusions: This combined procedure allows repair of fair- to poor-function ptosis in patients in whom ptosis surgery previously has been considered risky. For the authors, this technique has been proven safe and effective and should be considered in any patient population with compromised corneal protective mechanisms.

Thirty canaliculi of 18 patients with complete or nearly complete canalicular obstruction were subjected to laser canaliculoplasty as a substitute for the standard Jones-type bypass conduct. Etiologies for the obstruction included congenital lacrimal system atresia, eyelid trauma, scarring following previous lacrimal surgery, and chronic inflammatory fibrosis. The procedure utilized a holmium laser delivered via a 1,000 mu optical fiber to cut a 1-mm channel from the punctum into the lacrimal sac. In nine eyes, this procedure was combined with a surgical dacryocystorhinostomy (DCR) for concurrent lower nasolacrimal duct obstruction. Silicone stents were left in place for 6 months postoperatively. Follow-up data were available for 28 canaliculi of 17 patients. Moderate or better improvement in symptomatic epiphora and evidence of canalicular patency to drainage was seen in 16 of 28 (57%) treated canaliculi, and significant improvement was recorded in 12 of 28 (43%). Although these figures are lower than those obtainable after repair of small areas of focal canalicular stenosis or obstruction, the procedure is superior to any previous attempts at reconstruction of extensive obstructions, short of placement of a Jones tube. When successful, this procedure offers re-establishment of a near normal physiologic system, and avoids the complications of and patient dissatisfaction associated with a Jones tube.

Botulinum toxin has become the initial treatment of choice for the management of essential blepharospasm, hemifacial spasm and other craniocervical dystonias. Numerous studies have confirmed a 90% to 95% response rate. Although a number of common side effects have been reported, the occurrence and incidence of rare local complications remains poorly understood. More importantly, the acute and chronic distant effects of botulinum toxin have not been clearly elucidated. A better understanding of such effects is essential if clinicians are to appropriately advise patients on the use of this therapeutic modality. This article is based on the Duke University experience in the management of over 500 patients with craniocervical spasm disorders, combined with a review of the published literature. These disorders include essential blepharospasm, oromandibular dystonia, hemifacial spasm, and torticollis. The incidence of side effects following more than 6000 treatments with botulinum toxin is presented. Pertinent research relating to the causes of these complications is also reviewed. The most common complications of treatment with botulinum toxin are related to acute local effects resulting from chemodenervation. The most important clinical effect in this group is weakening of the levator muscle resulting in ptosis, and the corneal consequences of lagophthalmos. The latter includes exposure keratitis, dry eyes, blurred vision, and hypersecretion epiphora. Less common local effects include facial numbness, diplopia, and ectropion. Some distant effects are being observed with increasing frequency. These include pruritus, dysphagia, nausea, and a flu-like syndrome. Most significant, however, are the rare reports of generalized weakness and the documentation of EMG abnormalities distant to the site of toxin injection. This has been seen with injections for both blepharospasm and torticollis. Until further studies on the long-term distant complications of botulinum toxin are available, it is recommended that patients receive as few life-time doses of toxin as possible, consistent with adequate management of their spasms. The practice of reinjecting patients routinely every three months, or at the first return of mild spasms should be discouraged.

Gliomas of the anterior visual pathway are rare orbital lesions accounting for 65% of all intrinsic optic nerve tumors. These lesions occur principally among children in the first decade of life. They appear to be true neoplasms that characteristically show early growth, followed by stability in many patients. Visual prognosis is fair, and the outlook for life depends upon tumor location. When initially confined to the optic nerve alone, overall mortality is about 5%. Once the hypothalamus is involved, mortality rises sharply to over 50%. With involvement of the chiasm or hypothalamus, no form of therapy significantly alters the final outcome. Because of their indolent course, gliomas may be followed conservatively when confined to the optic nerve. In these cases, surgery is indicated only when blindness and pain or severe proptosis intervene. However, all such patients should be followed radiologically for evidence of posterior extension. When the chiasm is threatened, surgical excision via a craniotomy approach is warranted to prevent subsequent hypothalamic or third ventricle involvement. Malignant optic glioma is a distinct disease primarily affecting middle-aged adults. The chiasm is always involved, and although one eye may be spared initially, rapid progression to bilateral blindness is usual. The disease is uniformly fatal.

Background: The authors present a case of Hürthle cell carcinoma metastatic to the uvea in a patient with known Hürthle cell tumor of the thyroid. The fluorescein angiogram suggested a neoplastic lesion, and the collar-button configuration resembled a malignant melanoma. However, standardized echography revealed high internal reflectivity and an irregular acoustic structure suggestive of a metastatic carcinoma., Methods: The clinical history and examination were consistent with the diagnosis of metastatic Hürthle cell carcinoma of the eye. Results of a fine-needle aspiration biopsy and histopathology of the intraocular lesion confirmed the diagnosis., Results: Because this was the patient's better-seeing eye, the tumor was treated with an 125I radioactive episcleral plaque. Over the subsequent 27 months, the lesion demonstrated a gradual regression., Conclusions: We have not found any previously reported cases of Hürthle cell carcinoma of the thyroid metastatic to the eye. The diagnosis may be confirmed safely by intraocular aspiration biopsy. The lesion is responsive to radioactive plaque application. The origin, pathology, and management of this unusual tumor are reviewed.

In treating periocular basal cell carcinoma the goal is to achieve the most complete eradication of affected tissue while preserving as much healthy tissue as possible. In the first of these "Viewpoints" articles, Drs. Leshin and Yeatts discuss the success of Mohs' microsurgical technique (MMS) in both regards. Moreover, they note that MMS offers the additional advantage of placing all surgical and histological phases of tumor excision in the hands of one specialist, thus circumventing problems that may arise with procedures requiring the separate involvement of several specialists. In the second article, Drs. Anscher and Montana point out that modern radiotherapy techniques may offer adequate tumor control with less damage to surrounding tissues than is caused by surgical excision and reconstruction. With small lesions, radiotherapy has a success rate similar to that of surgery. With large lesions, the success rate is lower; however, if surgical excision would cause extensive disfigurement or functional damage, an initial trial of radiotherapy may be warranted, then followed by surgery, if necessary. In an editorial, Dr. Dutton summarizes the indications for and advantages and disadvantages of both techniques.

Meningiomas are benign neoplastic lesions arising from meningothelial cells of the meninges. Primary orbital meningiomas, originating in the optic nerve sheath, represent 1-2% of all meningiomas, and are the second most common optic nerve tumor after gliomas. They primarily affect middle-aged adults. Patients typically present with visual loss, frequently associated with optic atrophy and often with optociliary shunt vessels. The lesion is usually unilateral, but is bilateral in about 5% of cases. Meningiomas show characteristic indolent growth over years, progressing inexorably to blindness in the affected eye. Management should be conservative in most cases. In very rare situations, surgery has improved visual prognosis. In most patients, however, surgery offers no benefit, and should be reserved for those with blindness or severe proptosis, or when extension toward the optic canal is documented. Although preliminary results of radiotherapy are encouraging, very few patients have been treated using this modality, and the long-term advantage for vision remains unproven. Even when untreated, the prognosis for life is excellent, with an overall tumor-related mortality of 0%.

Twelve patients received a coralline hydroxyapatite sphere as a buried integrated ocular implant after enucleation surgery. The implant was modified by drilling 5 access holes, 1 mm in diameter, to the center of the sphere to allow more rapid host tissue ingrowth. 99Tc MDP static and dynamic bone scan studies were performed at various intervals after implantation to confirm the time course for vascularization. Complete vascularization was noted in 1 of 2 patients at 8 weeks after surgery, in 7 of 7 patients at 10 to 12 weeks, and in 3 of 3 patients at 16 weeks. This modified technique allows the hydroxyapatite ocular implants to be drilled for the final motility peg at an earlier time than currently possible, thereby resulting in more rapid cosmetic rehabilitation and obviating the need for secondary modification or replacement of the prosthesis.

Coralline hydroxyapatite spheres are used as buried integrated ocular implants after enucleation or evisceration surgery. Because such implants are used after surgery for intraocular malignancy and because some patients may require postoperative radiation therapy for orbital tumor recurrence, the radiation attenuation characteristics of the implant are of interest. The authors evaluated the attenuation and scattering properties of coralline hydroxyapatite implants using a 4 MV photon beam and film dosimetry. Optical density analyses indicate that coralline hydroxyapatite implants have no significant influence on the attenuation or scattering properties of the photon beam. As such, there is no basis for concern that such implants might adversely affect external beam photon irradiation.

We reviewed patient records of 99 consecutive orbital exenterations performed between 1969 and 1988. Patients ranged in age from 2 to 86 years (mean, 55.9 years). Classification of cases on histopathologic criteria showed 32 exenterations were performed for squamous cell carcinoma originating in the paranasal sinus (13), skin (12), conjunctiva (six), and lacrimal sac (one). Orbital exenteration was performed for treatment of other epithelial malignancy in basal cell carcinoma (eight), sebaceous carcinoma (six), adenoid cystic carcinoma (five), undifferentiated carcinoma (four), adenocarcinoma (two), intraepithelial carcinoma of the conjunctiva (two), benign mixed tumor (one), and transitional cell carcinoma (one). Exenterations were performed for melanoma of the conjunctiva (ten), nasosinus (three), skin (two), orbit (two), and choroid (one). Exenterations were also performed as treatment for mucormycosis (five), meningioma (three), fibrosarcoma (two), rhabdomyosarcoma (two), hemangiopericytoma (two), orbital cellulitis (one), fibrous histiocytoma (one), schwannoma (one), lymphangioma (one), benign lymphoepithelial lesion (one), and undifferentiated malignancy (one).