Search

PURPOSE: Epiphora remains an often difficult to manage ocular complaint for ophthalmologists in all subspecialties. This review seeks to examine the safety and efficacy of botulinum toxin injection for management of chronic epiphora. METHODS: The authors conducted a Pubmed search for studies on the use of lacrimal and transplanted salivary gland botulinum toxin injections for the management of epiphora within the past 20 years. Studies included had a minimum of four glandular injections. RESULTS: The authors identified 14 studies and divided them by indication for injection; either functional epiphora, non-functional epiphora, or mixed studies. Seven studies examined injections for cases of functional epiphora, four for non-functional epiphora, and four for mixed cases. The number of glandular injections reported ranged from 4 to 65. Side effects reported were limited to diplopia, eyelid or lacrimal gland hematoma, papillary conjunctivitis, dry eye, ptosis, and bleeding. CONCLUSIONS: Glandular botulinum toxin injection should be considered as a viable treatment strategy for both functional and nonfunctional epiphora. From the studies reviewed, botulinum toxin injection was shown to be effective in both children and adults. Injection can be performed in the outpatient setting, is minimally invasive, technically easy to administer, has a favorable side effect profile, and good efficacy. Furthermore, repeat injections can be performed with similar efficacy.

The authors present 3 patients from this retrospective case series to review the clinical findings, imaging, pathology, and treatment of orbital atypical lipomatous tumor/well-differentiated liposarcoma. Pathology of biopsy specimens ranged from spindle cell proliferations mimicking neurofibroma to proliferations of well-differentiated adipocytes. Immunohistochemical stains were positive for murine double minute 2 in 1 case, and fluorescent in situ hybridization showed amplification of murine double minute 2 in 2 cases. Treatments ranged from serial debulking, proton beam irradiation, and exenteration. None of the patients developed metastases. A literature review supported the low-grade nature of this lesion. Orbital atypical lipomatous tumor/well-differentiated liposarcoma is a low-grade, indolent liposarcoma that may be locally invasive. The histologic diagnosis is enhanced with immunohistochemical staining for murine double minute 2 and fluorescent in situ hybridization analysis for amplification of murine double minute 2. Although treatment may vary according to the individual, conservative therapies may be attempted prior to radical surgery.

Purpose Optic nerve sheath fenestration (ONSF) is a common surgical option for patients with idiopathic intracranial hypertension (IIH) with vision loss refractory to medical management. Little is known about the visual benefit of repeated ONSF. The authors aimed to assess the efficacy of secondary and tertiary ONSF in patients with IIH. Methods A retrospective chart review was performed on all patients with repeat ONSF for IIH at Emory University from 1999 to 2016. Primary outcome measures included visual acuity, optic nerve head findings, and visual field results. Results A total of nine eyes in seven patients (five females and two males) with repeat ONSF were identified. Two of the seven patients had repeat ONSF in both eyes, while the remaining five patients had only one eye repeated. Five of seven patients (five eyes) improved or remained stable after the secondary ONSF. Two patients (three eyes) continued to worsen despite the secondary fenestration surgery and underwent tertiary ONSF at an average of 13.2 months (SD 5.5 months) after the failed secondary ONSF. Both patients that underwent the tertiary fenestration showed improvement. Six of the patients had either improvement or stability in their clinical findings at their last documented follow-up, but one continued to worsen despite intervention. Conclusions This study suggests that secondary and tertiary nerve sheath fenestration is a viable management option for patients with progressive vision loss from IIH. Repeat ONSFs do not appear to have increased complication or failure rates compared to prior documented studies regarding primary fenestrations.

Bleomycin sclerotherapy has been shown to be a viable treatment for lymphatic malformations. However, its use for these lesions confined to the orbit is becoming increasingly documented in the literature. In this study, we summarize the clinical manifestations and outcomes observed following percutaneous bleomycin sclerotherapy for orbital lymphatic malformation.A 5-year retrospective chart review of patients with clinical, radiographic, and/or biopsy-confirmed diagnoses of orbital lymphatic malformation that received bleomycin sclerotherapy was conducted at the Emory Hospital and Clinics. Data examined included patient demographics, patient history and symptoms, clinical findings, radiographic findings, route of bleomycin delivery, and outcome.Of the 10 patients who met inclusion criteria, the median age of treatment was 7 years. The most common presenting symptoms included vision change and proptosis. Nine of 10 patients demonstrated macrocysts (1 cm) on imaging. Seven of 10 patients had histories of prior interventions including resections, cyst drainage, and debulking. Because 2 of these 10 patients were lost to follow-up, 8 patients remained for post-procedural evaluation. Four of these eight showed improvement of visual acuity after post-bleomycin sclerotherapy. In seven of eight patients, extraocular motility either improved or remained stable. Pretreatment and posttreatment exophthalmometer measurements obtained in four patients revealed an average improvement in proptosis of 65% from their average pretreatment measurements.Our findings suggest that percutaneous bleomycin sclerotherapy is a viable option for treatment of orbital lymphatic malformations, with potentially greater benefit to those with macrocystic features.

Periorbital nerve enlargement commonly indicates perineural invasion of malignancy or inflammatory conditions. This study reviews the role of supraorbital and infraorbital nerve biopsies in patients presenting with radiographic enlargement and to elucidate the surgical technique involved. A retrospective chart review (1997-2014) was performed at a single tertiary center. Patients with radiographic confirmation of enlarged supraorbital/infraorbital nerves that underwent biopsy were included. Charts were reviewed for: patient demographics and history, clinical symptoms and findings, radiographic findings, surgical method, and treatment. Five patients (4 female, 1 male) met inclusion criteria. Average age was 72.4 years (range 36-90). Four patients had history of cutaneous malignancy. All presented with diplopia and/or dysesthesias. Clinical examination confirmed decreased V1 and/or V2 sensation for 4 patients. Imaging revealed enlargement of V1, V2, and/or V3 in all patients. Infraorbital nerve biopsies were performed in 3 patients via transconjunctival fornix-based orbitotomy with subperiosteal dissection along orbital floor followed by unroofing of infraorbital canal. The remaining 2 underwent supraorbital nerve biopsy via sub-brow incision onto superior orbital rim with reflection of periosteum. Biopsies confirmed squamous cell carcinoma(3), mucoepidermoid carcinoma(1), and idiopathic orbital inflammation(1). Three patients initiated treatment in

Purpose To present a modification of the Hughes tarsoconjunctival flap to correct a case of refractory lower eyelid retraction. Methods The authors report a 49-year-old man with cicatricial right lower eyelid retraction that failed multiple surgical interventions, including ear cartilage grafts to the posterior lamella, tarsal strip, alloplastic implant, and Sub-Orbicularis Oculi Fat (SOOF) lift. A modified Hughes tarsoconjunctival flap was used for repair of a nonmarginal defect of the lower eyelid. A marginal defect was purposely created with a full-thickness blepharotomy that compensated for the amount of lower eyelid retraction. The posterior lamellar defect was filled with the tarsoconjunctival-Muller's flap and the anterior lamella defect covered with a full-thickness retroauricular skin graft. Mueller's muscle was included in the flap to increase the vascular supply to the reconstructed eyelid. Likewise, the authors waited 9 weeks to divide the flap because of concerns that the vascular supply of the surrounding eyelid might be compromised from multiple previous surgeries. Results A single case of cicatricial right lower eyelid retraction status after multiple failed surgical interventions successfully completed a full-thickness blepharotomy with a modified Hughes tarsoconjunctival flap. Two months after the procedure, the patient had good cosmesis and function with resolution of his signs and symptoms of exposure keratopathy. Conclusions The Hughes tarsoconjunctival flap combined with a full-thickness blepharotomy may be a useful technique in selected patients for repair of nonmarginal defects of the lower eyelid when other standard techniques have failed.

Alveolar soft-part sarcoma (ASPS) is a translocation-associated sarcoma that occurs most commonly in the lower extremities and rarely in orbit. Only 34 orbital cases have been reported in the literature, and it is often misdiagnosed due to its rare occurrence and nonspecific clinical findings. The optimal treatment remains controversial, although in general, aggressive surgical resection is advocated. Here, the authors present 2 cases of orbital ASPS and a review of the literature.

Langerhans cell histiocytosis (LCH) is a proliferation of Langerhans cells intermixed with inflammatory cells, in particular eosinophils, that may manifest as unisystem (unifocal or multifocal) or multisystem disease. Orbital involvement typically manifests as a solitary lesion that carries a favorable prognosis. Herein, we describe the clinical and histologic spectrum of LCH of the orbit on the basis of five cases. One patient exhibited multifocal unisystem disease, the other four patients presented with a localized process. The typical histologic features included numerous histiocytes with varying degrees of giant cell formation and scattered eosinophilic granulocytes. The presence of Langerhans cells was confirmed by CD1a and S100 immunostaining. Transmission electron microscopy exhibited characteristic intracytoplasmic Birbeck granules. The different ophthalmic manifestations of LCH and treatment strategies are reviewed in the context of previously reported cases. As LCH may solely involve the orbit, treatment is based on the degree of organ involvement. LCH has to be included in the differential diagnosis in tumors of the ocular adnexae, in particular in young children.

Purpose To retrospectively evaluate institutional outcomes for patients treated with modern radiation therapy (RT) for biopsied orbital pseudotumor (OP). Methods and Materials Twenty patients (26 affected orbits) with OP were treated with RT between January 2002 and December 2011. All patients underwent biopsy with histopathologic exclusion of other disease processes. Sixteen patients (80%) were treated with intensity modulated RT, 3 (15%) with opposed lateral beams, and 1 (5%) with electrons. Median RT dose was 27 Gy (range 25.2-30.6 Gy). Response to RT was evaluated at 4 months post-RT. Partial response (PR) was defined as improvement in orbital symptoms without an increase in steroid dose. Complete response (CR) 1 and CR 2 were defined as complete resolution of orbital symptoms with reduction in steroid dose (CR 1) or complete tapering of steroids (CR 2). The median follow-up period was 18.6 months (range 4-81.6 months). Results Seventeen patients (85%) demonstrated response to RT, with 7 (35%), 1 (5%), and 9 (45%) achieving a PR, CR 1, and CR 2, respectively. Of the 17 patients who had ≥PR at 4 months post-RT, 6 (35%) experienced recurrence of symptoms. Age (>46 years vs ≤46 years, P =.04) and clinical response to RT (CR 2 vs CR 1/PR, P =.05) were significantly associated with pseudotumor recurrence. Long-term complications were seen in 7 patients (35%), including 4 with cataract formation, 1 with chronic dry eye, 1 with enophthalmos, and 1 with keratopathy. Conclusions RT is an effective treatment for improving symptoms and tapering steroids in patients with a biopsy supported diagnosis of OP. Older age and complete response to RT were associated with a significantly reduced probability of symptom recurrence. The observed late complications may be related to RT, chronic use of steroids/immunosuppressants, medical comorbidities, or combination of factors.

A case of a pleomorphic adenoma of the lacrimal gland with a prominent clear cell myoepitheliomatous component was reported. An 81-year-old Caucasian woman experienced a 2-month history of right supraorbital swelling and proptosis. Excisional biopsy revealed a multicomponent lesion including a stromal component featuring glandular structures made of small epithelioid and spindle cells and a trabecular component with small islands of vacuolated cells, displaced nuclei, and clear cytoplasm. Immunohistochemical analysis revealed strong cytokeratin AE1/3 reactivity and focal smooth muscle actin positivity. The pathologic findings including immunohistochemistry results were consistent with a pleomorphic adenoma with prominent clear cell myoepithelioma component.

A 58-year-old Caucasian woman with thyroid eye disease underwent a bilateral lower eyelid blepharoplasty with porcine decellularized membrane (TarSys) eyelid spacer graft placement. Three months postoperatively, she developed unusual cyst-like masses in both lower eyelids that were excised. These were found to be consistent with inflammatory cysts with a foreign body reaction. No such reaction has ever been reported.

Corneal keloid, first described in 18651, is a rare condition consisting of a proliferation of benign fibrovascular tissue. There have been approximately 76 documented cases of corneal keloid previously reported.1–26 Most reported cases have occurred secondary to penetrating injury or surgery and it is thought that inflammation causes a fibroblastic reaction resulting in the keloid.24,27 Herein, we report a case of corneal keloid that developed in a patient with no history of ocular surgery or trauma. There have been other instances where corneal keloid formed in patients without prior corneal injury. Our patient had a remote history of radiation therapy for an orbital tumor and a tarsorraphy, which may have contributed to the keloid formation.

Purpose To report the clinicopathologic features of 3 patients with CD30 + lymphoid proliferations of the eyelid. Design Retrospective case series. Participants Patients with cutaneous CD30 + lymphoproliferative lesions of the eyelid. Methods Three patients with CD30 + non-mycosis fungoides T-cell lymphoid infiltrates of the eyelid were identified. The histories, clinical findings, pathologic features including immunohistochemical staining, treatments, and outcomes were reviewed and compared. Main Outcome Measures Pathologic findings including immunohistochemical analysis. Results The patients included an 81-year-old man, an 18-year-old man, and a 42-year-old woman with CD30 + lymphoid proliferations of the eyelid and adjacent soft tissue. The first patient had an isolated crateriform eyelid lesion that was classified as lymphomatoid papulosis (LyP). The second patient had an isolated multinodular lesion of the eyelid that was classified as cutaneous anaplastic large cell lymphoma (cALCL). The third patient presented with eyelid edema with an underlying mass and was found to have widely disseminated anaplastic large cell lymphoma (ALCL). Diagnoses were dependent on clinical findings. Conclusions The CD30 + lymphoid proliferations represent a spectrum of conditions ranging from indolent LyP, to moderately aggressive cALCL, to highly aggressive ALCL. Interpretation of the pathologic findings in CD30 + lymphoid proliferations is based in part on clinical findings. Financial Disclosure(s) The authors have no proprietary or commercial interest in any material discussed in this article.

PURPOSE To describe the technique of percutaneous, infraocular embolization of indirect carotid-cavernous fistulas (CCFs) and analyze the results in a small clinical series. METHODS A retrospective case series of 4 patients treated at Emory University Hospital. RESULTS Four patients with indirect CCFs and limited transvenous access were successfully treated with transcutaneous, infraocular embolization of the recipient cavernous sinus via the ipsilateral superior orbital fissure. Main outcome measures were clinical examination findings and cerebral angiography. All patients had either preservation or improvement in final visual outcome. One patient required early retreatment because of clot lysis and reopening of a secondary, iatrogenic direct CCF. Two patients suffered early postprocedural orbital hemorrhage requiring treatment with lateral canthotomy and inferior cantholysis. CONCLUSIONS Based these findings, percutaneous, infraocular, trans-superior orbital fissure embolization of CCFs is a viable alternative in patients with refractory fistulas failing management with more conventional techniques. Orbital hemorrhage is a significant risk, and availability of an ophthalmologist skilled in the management of this complication is imperative.

Objectives Epiphora results from obstruction along the nasolacrimal (NL) system. The inferior meatus (IM) is not routinely evaluated. IM pathology is common in patients with epiphora, allowing surgery to be directed at the IM. Methods Retrospective review of patients referred for epiphora. Patients underwent office endoscopy of the IM. Patients with identifiable pathology underwent intervention directed at the IM. Results Seventeen patients were evaluated, four with bilateral epiphora. Two had no IM disease, and one with pathology refused surgery. The remaining 14 (18 sides) had IM pathology. Two patients were successfully treated in the office. Twelve patients underwent surgery (16 sides). Three NLD orifices were obstructed by a cyst, and the remaining 13 by hypertrophied soft tissue at the level of the NLD orifice. Thirteen of 14 sides with distal NLD pathology had resolution or dramatic improvement and patent NL ducts with IM treatment alone. Obstruction extending proximal to Hasner's valve was found in four NL systems, and three developed recurrent epiphora. Median follow-up was 9 months. Conclusions IM endoscopy identified pathology in most constant epiphora patients in this study. Pathology at the distal NL system portends a better outcome, whereas extension to the proximal NL duct had poorer outcome.

Background: Epiphora is a common problem evaluated by ophthalmologists and otolaryngologists. It is typically the result of obstruction at some level of the nasolacrimal system, either the canaliculi, sac, or duct. Multiple etiologies exist, including scarring from infection or trauma, tumors, or masses. Cysts of the nasolacrimal duct orifice (dacryocystoceles) in the inferior meatus have been described in neonates, usually presenting as obstructive nasal masses shortly after birth. Nasolacrimal duct orifice cysts have not been described in the adult population in the medical literature. Patients: Three patients were identified with epiphora as a result of cysts in the inferior meatus at the opening of the nasolacrimal duct. All patients presented with constant epiphora and were referred for dacryocystorhinostomy by an ophthalmologist or an otolaryngologist. None of the patients had a previous history of nasolacrimal duct (NLD) surgery. One patient had previous endoscopic sinus surgery for nasal polyps. Cysts were identified by nasal endoscopy of the inferior meatus in all patients. Results: All patients underwent endoscopic resection of the inferior meatus cyst to relieve the obstruction of the NLD. Two procedures were performed under general anesthesia and one under intravenous sedation. All patients had complete relief of epiphora and have had no evidence of recurrence of the symptoms or the cyst in 4 to 10 months follow-up. Conclusions: NLD orifice cysts are easily correctable causes of epiphora. Routine inferior meatus endoscopy should be routinely performed in patients with epiphora to identify whether on not this pathology is present prior to performing dacryocystorhinostomy.

Prolapse of subconjunctival intraconal orbital fat is a rare cause of an intraorbital mass lesion. Over the past several years, we have seen a number of cases in which this prolapsed fat was confused pathologically with a neoplasm of adipocytic lineage, specifically pleomorphic lipoma and atypical lipomatous neoplasm (well-differentiated liposarcoma). We report the clinical, histopathologic, and immunohistochemical findings in 21 specimens from 17 patients, all of whom presented with prolapsed intraconal orbital fat. All specimens were routinely examined and processed for light microscopy. Immunohistochemistry for CD34, CD68, S100 protein, vimentin, alpha-smooth muscle actin, and Ki-67, and Giemsa, Masson trichrome, and alcian blue histochemical stains were performed. Clinical and follow-up information was extracted from a chart review. The mean age (+/-SD) of the patients was 65.6+/-11.9 years (range: 41 to 85 y); 2 were women and 15 were men. Subconjunctival prolapsed orbital fat was localized in the superotemporal quadrant or lateral canthus around the rectus muscle below the lacrimal gland. The lesions were unilateral in 10 and bilateral in 7 patients. No recurrence was clinically evident over a mean (+/-SD) follow-up time of 2.5+/-3.2 years (range: 1 mo to 13.5 y). Histopathologically, all specimens showed an admixture of mature fat, fibrous septae lacking hyperchromatic cells, adipocytes with intranuclear vacuoles (Lochkern cells), multinucleated giant cells with a wreathlike configuration of normochromatic nuclei (floret cells), and varying numbers of histiocytes, lymphocytes, plasma cells, and mast cells. "Control" sections of normal orbital fat showed occasional Lochkern cells but lacked floret cells. By immunohistochemistry, the floret cells expressed only CD34 and vimentin, whereas the Lochkern cells expressed CD34, S100 protein, and vimentin. We conclude that subconjunctival herniated orbital fat commonly contains multinucleated floretlike giant cells, fibrous septae, and Lochkern cells, features that may result in diagnostic confusion with pleomorphic lipoma and atypical lipomatous neoplasms. Importantly, specific diagnostic features, such as aggregates of bland spindled cells associated with wiry collagen, as seen in pleomorphic lipoma, and enlarged hyperchromatic cells within fibrous septae, as in atypical lipomatous neoplasms, are entirely absent in herniated orbital fat. Multinucleated floret cells present in prolapsed orbital fat likely represent a reactive phenomenon, as they are not present in normal orbital fat.

“But then science is nothing but a series of questions that lead to more questions, which is just as well, or it wouldn't be much of a career path, would it?”1 I enjoy an article that generates more questions and discussion than it answers. Such is the case with “Who is Publishing in Facial Cosmetic Surgery? A Citation Analysis Across Specialties Over Five Decades.”2 The authors seek to answer whether increased competition in the marketplace for cosmetic facial surgery procedures by otolaryngology, dermatology and ophthalmology is mirrored in the frequency of citations in facial aesthetic surgery in the peer reviewed literature of those same specialties. They found that plastic surgery had the highest percentage of citations across five decades in all aspects of facial aesthetic surgery, with the exception of rhinoplasty, which has favored otolaryngology since the year 2000. Additionally, all of the other specialties studied generally showed increasing percentages of citations with the passage of time. Thus, the increased competition for facial aesthetic procedures by these specialties seen in the marketplace is indeed mirrored by the frequency of similar journal publications. So, what does this …

Purpose To describe two patients with arachnoid cysts of the optic nerve mimicking optic nerve/orbital neoplasms. Methods The histories, ophthalmic examinations, and pathologic findings of two patients with arachnoid cysts of the optic nerves were reviewed and compared with previously reported cases. Results One patient had progressive proptosis and the other had decreased vision with visual field changes. Pathologic examination of optic nerve sheath biopsies showed redundant proliferations of meningothelial cells with associated thickened dura. Conclusions Arachnoid cysts of the optic nerve are benign, slowly progressive conditions that may result in proptosis and visual field changes. The clinicopathologic features of arachnoid cyst should be differentiated from optic nerve sheath meningioma and other conditions.

Purpose To describe the clinical features, histologic findings, flow cytometric immunophenotypes, and molecular profiles of ocular adnexal lymphoid proliferations. Study design Prospective noncomparative case series. Participants Forty-three patients suspected of having ocular adnexal lymphoid proliferations were biopsied and prospectively evaluated. Methods Provisional diagnoses were made on the basis of routine histology and immunohistochemistry for B and T cells. Results of flow cytometric immunophenotyping (FCI) and molecular assessment using polymerase chain reaction for immunoglobulin heavy chain (IgH) and TCR gamma chain gene rearrangement and bcl-2/IgH translocation were then incorporated into a final diagnosis. Demographic and clinical outcome data were collected. Main outcome measures Final diagnosis based on histology, flow cytometry, and polymerase chain reaction. Results Forty-three cases were studied. Final diagnoses included 17 lymphomas, 18 chronic inflammations, 4 reactive lymphoid hyperplasias, and 4 atypical lymphoid infiltrates. Preliminary evaluation accurately categorized all 43 cases as either lymphoma or nonlymphoma. FCI permitted more precise subclassification of the lymphomas according to the Revised European American Lymphoma (REAL) system of nomenclature as follows: eight marginal zone B cell (mucosa-associated lymphoid tissue type), three mantle cell, two follicular, three large cell, and one lymphoplasmacytoid lymphoma. FCI showed a clonal B cell proliferation in 94% (16 of 17) of the lymphomas; FCI identified a clonal B cell population in 4% (1 of 25) of cases of nonlymphomas. Molecular evidence of clonality was identified in 88% (15 of 17) of lymphomas, 39% (7 of 18) of chronic inflammations, and 50% (4 of 8) of reactive lymphoid hyperplasias and atypical lymphoid infiltrates. Conclusions The histologic diagnosis of ocular adnexal lymphoid lesions is highly accurate when determined by an experienced pathologist. FCI refines the histologic diagnosis and classification. Results of molecular studies should be interpreted in conjunction with clinical, histologic, and immunophenotyping findings.

A 50-year-old African American woman with right proptosis and decreased vision demonstrated symmetric, bilateral thickening of the sphenoid wings, calvarium, and skull base on computed tomography. Histopathologic evaluation of the hyperostotic lesion was consistent with meningotheliomatous meningioma. The patient underwent uncomplicated right frontal orbital craniectomy with postoperative radiation. The presentation of en plaque meningioma, when diffuse and symmetric, can mimic a metabolic disease of bone.

Purpose To describe the author's experience with the use of botulinum toxin (Botox, Allergan Inc., Irvine, CA, U.S.A.) injection in the palpebral lobe of the lacrimal gland for symptomatic epiphora due to lacrimal obstruction or gustatory tearing. Methods This is a retrospective review of 46 patients treated by the author with botulinum toxin injection in the palpebral lobe of the lacrimal gland for symptomatic epiphora due to lacrimal obstruction or gustatory tearing from 2001 through 2008. All patients were injected with 2.5 units of botulinum toxin, and the patients' subjective responses were assessed 1 to 2 weeks later. If there was insufficient response, they were reinjected with an additional 2.5 units of botulinum toxin and re-evaluated in 1 to 2 weeks. The response to the treatment and complications were evaluated. Results Overall, 74% of patients treated felt that tearing was mostly or completely improved. The only complication was temporary ptosis in 11% of the patients. Conclusion Botulinum toxin injection in the palpebral lobe of the lacrimal gland can be used effectively and safely for symptomatic epiphora due to lacrimal obstruction and gustatory tearing. Although the beneficial results are temporary, the patient satisfaction in selected patients is high.

PURPOSE To determine the results with a Medpor-coated tear drain in conjunctivodacryocystorhinostomy. METHODS This was a retrospective case review of all patients who underwent conjunctivodacryocystorhinostomy with a Medpor-coated tear drain by the author. The success rate and complications were determined. RESULTS Sixteen patients had placement of 17 Medpor-coated tear drains. Twelve of the 16 patients (75%) were doing well at the last follow-up visit with a well-positioned, functioning tear drain tube. Four patients (25%) required tube removal for assorted reasons, 2 of whom had an early prototype of the tube. CONCLUSION The Medpor-coated tear drain is an effective device for bypass of the lacrimal drainage system in conjunctivodacryocystorhinostomy. The current design of the tube should minimize complications while ensuring stable placement and retention.

A 27-year-old woman developed a rapidly progressive left orbital tumor that extended in the cranial fossa. MRI revealed a heterogenous enhancing lesion confined to the left frontal bone and superior orbit. An incisional biopsy was performed, and histopathologic examination of the specimen showed fin

Objective: To report on patients with mucinous eccrine adenocarcinoma of the eyelid. Design: Retrospective case series. Participants: Biopsy specimens of 6 patients with eyelid neoplasm were obtained. The pathologic diagnoses were mucinous eccrine adenocarcinomas. Methods: The medical records, including demographic, clinical, histopathologic, and follow-up information, were reviewed. Results: Five patients underwent surgical removal of the lesion by means of Mohs micrographic surgery. Four of these patients were doing well; 1 of them, with positive margins of resection, had 2 recurrences. One case was lost to follow-up. Conclusions: Mucinous eccrine adenocarcinoma is an uncommon adnexal tumour that can involve the eyelid, has low metastasis and mortality, but can be invasive or locally recur. Mohs micrographic surgery is a recommended treatment of mucinous eccrine adenocarcinoma of the eyelid.

To report a case of mucoepidermoid carcinoma of an accessory lacrimal gland with orbital invasion.The clinical history and pathologic findings of a patient with a left upper eyelid lesion were reviewed.The patient was evaluated and found to have an epithelial tumor arising in an accessory lacrimal gland. Special stains showed mucin production by individual tumor cells. The tumor was classified as mucoepidermoid carcinoma.Mucoepidermoid carcinoma may arise in accessory lacrimal glands and invade the orbit.

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

Morris E. Hartstein, Guy G. Massry, and John B. Holds, eds. Pearls and Pitfalls in Cosmetic Oculoplastic Surgery . New York, NY: Springer, 2015. ISBN-10: 1493915436, ISBN-13: 978-1493915439, $249.00. ![Graphic][1] This is the second edition of this textbook, which now contains 203 short chapters on various aspects of cosmetic oculoplastic surgery in almost 700 pages. The editors are experienced and respected surgeons, and contributions come from 112 authors in the fields of oculoplastic surgery, plastic surgery, facial plastic surgery, dermatology, and oral surgery. The concept of the book is to provide brief discussions in a “how I do it” style on the gamut of procedures in oculoplastic surgery, where each chapter may cover a very specific part of a procedure. For example, there are about ten chapters on how to manage the fat in lower lid blepharoplasty and seven chapters on how to design the incision in upper eyelid blepharoplasty. There is considerable and purposeful repetition so as to reflect the preferences and nuances of different surgeons. The book is divided into 25 sections … Corresponding Author: Dr Ted Wojno, The Emory Clinic-B, 1365 Clifton Road NE, Atlanta, GA 30322. E-mail: ophttw{at}emory.edu [1]: /embed/inline-graphic-1.gif

· Purpose: We report a 50-year-old man with end-stage renal disease who has developed bilateral inner and outer canthal nodules. · Methods: The nodules were excised, fixed in 10% formalin and 2.5% glutaraldehyde, and processed for light and electron microscopy, respectively. · Results: Histological examination showed elastotic changes with associated granulomatous inflammation. The granulomatous reaction was centered around elastotic fibers, and some giant cells engulfed the fibers. Areas of dystrophic calcification were identified. A diagnosis of actinic granuloma was made. The differential diagnosis and histopathology of actinic granuloma, i.e. granuloma annulare, rheumatoid nodule, and necrobiotic xanthogranuloma, are discussed. · Conclusion: This case of an actinic granuloma originating in the sun-damaged periocular skin provides further evidence that elastotic degeneration may be associated with a giant cell reaction. It is, however, unclear which antigens are responsible for initiating the granulomatous response and whether elastotic material on its own can elicit a granulomatous reaction.

Purpose: To report three patients with superficially invasive crateriform squamous proliferations of periocular tissue. Methods: The authors identified three patients with superficially invasive periocular tumors that had clinical features of keratoacanthoma. Clinical histories, radiographs, and surgical pathologic specimens were reviewed. Results: All three tumors arose over several weeks, had a crateriform configuration, and exhibited superficial invasion of underlying tissues, including perineural invasion and infiltration into skeletal muscle. All three tumors were classified as invasive keratoacanthoma. One tumor exhibited late perineural extension into the cavernous sinus and convincing histologic features consistent with squamous cell carcinoma. Conclusion: The clinical importance of recognizing invasive keratoacanthoma is that although the tumor has the potential for spontaneous involution, locally aggressive behavior with deep perineural invasion is possible. This tumor is considered to represent a variant of squamous cell carcinoma. The authors recommend complete surgical excision of crateriform squamous proliferations with frozen section control of margins of resection.

Introduction/purpose Despite benign histology, many congenital intra-orbital lesions have an aggressive prognosis owing to the confined orbital space and the intimate optic nerve association – resulting in pain, disfigurement, and vision loss. Complete surgical excision while preserving function may not be possible1 The use of conventional fluoroscopically guided interventions is limited due to inability to visualize soft tissue anatomy. We have previously presented our work evaluating the feasibility of applying interventional MRI technology to access and treat these challenging intraorbital lesions, and now present an update with new patients and multi-year follow up. Materials and methods Ten MRI-guided sclerotherapy procedures were performed on 4 patients (4M, 0F, age = 3–30y) presenting with cystic congenital intraorbital lesions. Patients presented with proptosis (n = 3), visual impairment (n = 2), diplopia (n = 1), ecchymosis (n = 2), and/or pain (n = 1). All procedures were exclusively performed within an interventional MRI suite with an in-room monitor used for real-time needle guidance, injection monitoring and bedside scanner operation. A 22 g MR-compatible needle was inserted into the targeted lesions under “MR-fluoroscopy” using triorthogonal image plane guidance2 to interactively monitor the needle on continuously updated sets of true-FISP images (TR/TE, 4.35/2.18; FA, 60°; NSA, 3; TA, 3.11 s/slice). 0.6% gadolinium was mixed with 5% Ethanolamine Oleate (Ethamolin®) (0.15 ml:1.0 ml vol.) and injected under real-time monitoring using a triorthogonal FLASH sequence (TR/TE,2484/5.4). Follow up on the earliest patients is available for three years. Results Intra-orbital needle insertion and subsequent repositioning were sucesfully performed in all cases. The flexibility of triorthogonal guidance was most helpful in accessing the intraconal retrobulbar space. Active monitoring of sclerosing agent was persistently achieved on 3 planes. Targeted lesions ranged between 1.5 and 4 cm. Three lesions encircled/abutted the optic nerve. Between 1–5.5 mls of sclerosing material were injected per procedure. The smallest lesion was completely filled with sclerosant during each of 2 treatment sessions, with 3 partially filled to avoid excessive intraorbital pressure. Local edema and bruising were a standard finding for 1–2 weeks afterwards. Complete imaging resolution of one lymphatic malformation occurred. The 3 other lesions significantly shrank, without delayed complications. Conclusion This report demonstrates long term success in using MRI technology to treat congenital intraorbital lesions, with no long term or delayed complications to date. This offers a new avenue for those patients who are typically deprived of surgical and other conventional interventional options. References 1 Chung EM, et al. Radiographics 2007;(27):1777–799. 2 Derakhshan JJ, et al. Proc ISMRM 15:487 (2007). Disclosures A. Nicholson: None. T. Powell: None. J. Saunders: None. B. Hayek: None. T. Wojno: None. S. Nour: None.

Background The optimal initial local treatment for patients with Graves’ ophthalmopathy (GO) is not fully characterized. The purpose of this retrospective study is to describe the clinical outcomes of RT as initial local therapy for GO and define predictors of the need for post-RT salvage bony decompressive surgery. Methods 91 patients with active GO and without prior surgery were treated with RT as initial local therapy between 01/1999 and 12/2010, with a median follow-up period of 18.3 months (range 3.7 - 142 months). RT dose was 24 Gy in 12 fractions. 44 patients (48.4%) had prior use of steroids, with 31 (34.1%) being on steroids at the initiation of RT. The most common presenting symptoms were diplopia (79%), proptosis (71%) and soft tissue signs (62%). Results 84 patients (92.3%) experienced stabilization or improvement of GO symptoms. 58 patients (64%) experienced improvement in their symptoms. 19 patients (20.9%) underwent salvage post-RT bony decompressive surgery. Smoking status and total symptom score at 4 months were independent predictors of post-RT bony decompression with odds ratios of 3.23 (95% CI 1.03 – 10.2) and 1.59 (95% CI 1.06 – 2.4), respectively. Persistent objective vision loss at 4 months post-RT was the most important symptom type in predicting salvage decompression. Chronic dry eye occurred in 9 patients (9.9%) and cataracts developed in 4 patients (4.4%). Conclusions RT is effective and well tolerated as initial local therapy for active GO, with only 21% of patients requiring decompressive surgery post RT. Most patients experience stabilization or improvement of GO symptoms, but moderate to significant response occurs in the minority of patients. Smoking status and total symptom severity at 4 months, primarily persistent objective vision loss, are the primary determinants of the need for post-RT salvage bony decompression. Patients who smoke or present with predominantly vision loss symptoms should be advised as to their lower likelihood of symptomatic response to RT and their increased likelihood of requiring post-RT decompressive surgery.

Idiopathic orbital inflammatory syndrome (IOIS) is a nonspecific inflammation of orbital tissue. As it is a diagnosis of exclusion, systemic testing and, at times biopsy, is utilized to rule out other inflammatory etiologies. Since some inflammatory etiologies that masquerade as typical IOIS can be vision or life threatening, it is important to consider these diagnoses. Systemic lupus erythematosus (SLE) is a chronic systemic autoimmune process that can affect the eye and visual system in 20% of individuals. In this idiopathic process, the deposition of pathogenic autoantibodies and immune complexes damage tissues and cells. Some common ocular manifestations of SLE include keratoconjunctivitis sicca, periocular skin lesions, orbital inflammation, retinal hemorrhages and vasculitis, retinal vaso-occlusive disease, iritis, scleritis, optic neuritis and optic neuropathy. One rare clinical entity in the SLE spectrum is panniculitis, also known as lupus erythematosus profundus (LEP), which is a nodular inflammation of adipose tissue. Panniculitis involving orbital structures as the primary presenting symptom of SLE is quite unusual and has only rarely been previously reported in the literature and has not been reported presenting as IOIS. This uncommon presentation can make the diagnosis more difficult. We describe a patient who had presented with ptosis evolving to orbital inflammation, which was consistent with IOIS by laboratory and histologic examinations. The patient later developed extensive panniculitis and a final diagnosis of LEP was made.

Intratarsal keratinous cysts are uncommonly reported entities that originate within the tarsal plate. Previously reported cysts have always been solitary, whether primary or recurrent. The authors present an unusual case of a 50-year-old man with 11 intratarsal keratinous cysts on a single eyelid. Complete excision of all the cysts was curative for at least 2 months.

A 69-year-old woman with a history of a previously resected right sphenoid wing meningioma and radiation presented with a 4-month history of a rapidly progressive right orbital swelling. MRI revealed a sphenoid wing mass extending in the right orbit and depressing the right globe. An incisional biopsy revealed a clear cell meningioma with anaplastic features. Histopathologic examination showed that the tumor was composed of sheets of polygonal cells with clear cytoplasm consistent with clear cell meningioma. Nuclear atypia with a high mitotic activity was also evident; thus, the tumor was classified as anaplastic. Clear cell meningioma is a rare form of meningioma usually located in the cerebellopontine or spinal cord areas.

The eyelids and eyeball are the focus of attention when we look at other people. The eyelid skin is the thinnest of any skin in the body. Even the slightest abnormality or asymmetry is thus immediately obvious to a casual examiner. The lid anatomy is fine and elegant but easily disrupted by pathology. This article explains the functional lid anatomy and discusses the common disorders affecting the lids. Treatment of these disorders is briefly explained.

Lichen planus is a chronic inflammatory disease that can affect both the skin and mucosa. Although more commonly affecting the oral and genital mucosa, it can also affect the conjunctiva, causing cicatrization in rare cases. It has been reported previously to be associated with hepatitis C infection, paraneoplastic conditions,1 systemic lupus erythematosus, Sjogren syndrome,2 and ocular cicatricial pemphigoid.3 It can be present in the mucosa as a reticulated network of white streaks or an erosive plaque-like process with multiple, recurrent, discrete lesions.4 We present a case of conjunctival lichen planus in a patient with a history of herpes simplex virus keratitis without cicatrization.

To report the clinicopathologic features of 3 patients with CD30(+) lymphoid proliferations of the eyelid.Retrospective case series.Patients with cutaneous CD30(+) lymphoproliferative lesions of the eyelid.Three patients with CD30(+) non-mycosis fungoides T-cell lymphoid infiltrates of the eyelid were identified. The histories, clinical findings, pathologic features including immunohistochemical staining, treatments, and outcomes were reviewed and compared.Pathologic findings including immunohistochemical analysis.The patients included an 81-year-old man, an 18-year-old man, and a 42-year-old woman with CD30(+) lymphoid proliferations of the eyelid and adjacent soft tissue. The first patient had an isolated crateriform eyelid lesion that was classified as lymphomatoid papulosis (LyP). The second patient had an isolated multinodular lesion of the eyelid that was classified as cutaneous anaplastic large cell lymphoma (cALCL). The third patient presented with eyelid edema with an underlying mass and was found to have widely disseminated anaplastic large cell lymphoma (ALCL). Diagnoses were dependent on clinical findings.The CD30(+) lymphoid proliferations represent a spectrum of conditions ranging from indolent LyP, to moderately aggressive cALCL, to highly aggressive ALCL. Interpretation of the pathologic findings in CD30(+) lymphoid proliferations is based in part on clinical findings.The authors have no proprietary or commercial interest in any material discussed in this article.

Objectives To document ophthalmic morbidity of golf-related injuries in children and to report specific injury patterns. Design A noncomparative, interventional, retrospective case series of 11 pediatric patients treated at 2 institutions for ophthalmic trauma resulting from golf-related injuries during 15 years. Results Eleven eyes of 11 patients were injured. There were 6 boys and 5 girls, with a mean age of 10.2 years (age range, 7-14 years). Ten patients were injured by golf clubs and 1 patient by a golf ball. One injury occurred on a golf course. At the initial ophthalmic examination, visual acuity was 20/20 in 4 eyes (36%), 20/25 to 20/80 in 3 eyes (27%), no light perception in 3 eyes (27%), and undeterminable in 1 eye (9%). Nine of 11 patients required surgery. Follow-up ranged from 0 to 66 months (mean follow-up, 12 months). Three of 11 subjects had permanent deficits, including blindness, decreased vision, and anophthalmia. Final visual acuity was no light perception in 2 eyes (18%), 20/70 in 1 eye (9%), and 20/20 or better in 8 eyes (73%). Conclusions The findings from this series reveal that pediatric ophthalmic golf injuries, although rare, may be devastating to the eye, periocular adnexa, and visual system. Among our cases, most injuries occurred off the golf course, many required surgery, and some resulted in permanent loss of vision.

Background Silent sinus syndrome (SSS) is an uncommon disease process, classically described as unilateral maxillary sinus opacification that presents with enophthalmos and atelectasis of bony sinus walls from chronic negative pressure. Patients are largely free of characteristic rhinosinusitis symptoms. Methods Operative reports, clinic notes, and radiological studies were reviewed for cases of SSS treated in a tertiary care institution over a 7-year period. Presenting symptoms, radiological features, and surgical findings were evaluated. Results Seventeen cases of SSS were identified. Presentation ranged from incidental computed tomography (CT) scan findings to unilateral enophthalmos with altered midface anatomy. Facial pain ipsilateral to the disease process occurred in 30% of cases. Vision changes were uncommon. Radiological studies universally revealed an opacified maxillary sinus on the affected side. Maxillary sinus walls were contracted and demineralized with significant orbital floor depression in 11 advanced cases. Four early cases revealed only lateralized uncinate process on CT scan without increased orbital volume, and two moderate cases showed increased orbital volumes on CT scan without clinical enophthalmos. All patients had a significantly lateralized uncinate process at surgery, often closely apposed to demineralized orbital walls. Conclusion Some authors maintain that SSS presentation must include enophthalmos. However, our series shows cases of lateralized uncinate processes and increased orbital volumes on CT scan, as would be seen in classic SSS, but lacking clinical enophthalmos. Such cases should be considered as potentially representing early SSS, before the development of clinical orbital findings.

Eyelash loss has many causes. The absence of lashes is frequently cosmetically objectionable for patients. Many techniques have been used to improve cosmesis, including tattooing and transplantation of cilia. This is a report on the result of individual hair follicle transplantation to the upper eyelids with a suboptimal outcome.

Purpose To report a group of patients with biopsy-proven orbital lymphangioma diagnosed late in life. Methods The clinical records and histopathologic findings of 3 patients with biopsy-proven orbital lymphangioma were reviewed. Results Three patients were identified who were diagnosed with orbital lymphangioma at the ages of 70, 80, and 82 years old. Each patient presented with different symptoms and signs including presence of a superficial mass, periorbital pain, and gradual painless proptosis, respectively. In one case, imaging revealed an isolated superficial mass, and in the other 2 cases it demonstrated the presence of a heterogeneous, cystic, retrobulbar mass. Pathologic findings in all cases included endothelium-lined channels with intervening fibrous septae infiltrated with aggregates of lymphocytes. Two of the three patients had complete excisions without recurrences and the third patient was followed after biopsy. Conclusions Lymphangioma, one of the most common vascular lesions in childhood, should also be included in the differential diagnosis of orbital masses in adults, including elderly adults.

Background The objective of this report is to describe the methods used to develop and validate a computerized system to analyze Humphrey visual fields obtained from patients with non-arteritic anterior ischemic optic neuropathy (NAION) and enrolled in the Ischemic Optic Neuropathy Decompression Trial (IONDT). The IONDT was a multicenter study that included randomized and non-randomized patients with newly diagnosed NAION in the study eye. At baseline, randomized eyes had visual acuity of 20/64 or worse and non-randomized eyes had visual acuity of better than 20/64 or were associated with patients refusing randomization. Visual fields were measured before treatment using the Humphrey Field Analyzer with the 24-2 program, foveal threshold, and size III stimulus. Methods We used visual fields from 189 non-IONDT eyes with NAION to develop the computerized classification system. Six neuro-ophthalmologists ("expert panel") described definitions for visual field patterns defects using 19 visual fields representing a range of pattern defect types. The expert panel then used 120 visual fields, classified using these definitions, to refine the rules, generating revised definitions for 13 visual field pattern defects and 3 levels of severity. These definitions were incorporated into a rule-based computerized classification system run on Excel® software. The computerized classification system was used to categorize visual field defects for an additional 95 NAION visual fields, and the expert panel was asked to independently classify the new fields and subsequently whether they agreed with the computer classification. To account for test variability over time, we derived an adjustment factor from the pooled short term fluctuation. We examined change in defects with and without adjustment in visual fields of study participants who demonstrated a visual acuity decrease within 30 days of NAION onset (progressive NAION). Results Despite an agreed upon set of rules, there was not good agreement among the expert panel when their independent visual classifications were compared. A majority did concur with the computer classification for 91 of 95 visual fields. Remaining classification discrepancies could not be resolved without modifying existing definitions. Without using the adjustment factor, visual fields of 63.6% (14/22) patients with progressive NAION and no central defect, and all (7/7) patients with a paracentral defect, worsened within 30 days of NAION onset. After applying the adjustment factor, the visual fields of the same patients with no initial central defect and 5/7 of the patients with a paracentral defect were seen to worsen. Conclusion The IONDT developed a rule-based computerized system that consistently defines pattern and severity of visual fields of NAION patients for use in a research setting.

Purpose To report a case of proliferating trichilemmal cyst in a 55-year-old woman. Design Observational case report. Methods A 55-year-old woman sought treatment for a mass in the right upper eyelid. The lesion was excised twice previously, and recurred. The mass was reexcised and examined histopathologically. Results Light microscopy showed a cystic lesion lined by stratified squamous epithelium with a compact layer of eosinophilic keratin without granular cell layer. There was no atypia, mitosis, or stromal invasion. Conclusions Although proliferating trichilemmal cyst shows benign histopathologic features, clinical manifestations may mimic those of more aggressive tumors with local recurrences or distant metastasis. Wide excision of the lesion and close long-term follow-up is recommended.