Surgical correction of severe congenital ptosis using a modified frontalis muscle advancement technique: A single-arm trial

PURPOSE

To describe our experience with a modified frontal muscle advancement flap to treat patients with severe congenital ptosis.

METHODS

Analysis of the clinical charts of 154 patients who underwent a modified frontal muscle advancement flap. The FM was exposed by a crease incision. The FM flap was created by deep dissection between the orbicularis muscle and orbital septum from the skin crease incision to the supraorbital margin and subcutaneous dissection from the inferior margin of the eyebrow to 0.5 cm above the eyebrow. No vertical incision was made on the FM flap to ensure an intact flap wide enough to cover the entire upper tarsal plate. Contour, symmetry of height, marginal reflex distance (MRD1), and complications were assessed. Mean follow-up was 10 months.

RESULTS

The mean patient age was 7.6 ± 5.6 (range, 2-18) years. The mean MRD1 was 3.2 ± 1.3 mm after the operation. All bilateral cases achieved symmetry and optimal lid contour; 17 unilateral cases were under corrected, with a success rate of 89.0%. Complications such as entropion, exposure keratitis, FM paralysis, frontal hypoesthesia, severe haematoma, and entropion were not observed in our series.

CONCLUSION

A modified frontal muscle advancement flap produced a high success rate with a clear field of vision, mild trauma, and few complications. This technique is relatively simple and should be considered for correcting severe congenital ptosis.Date of registration: 29-03-2020Trial registration number: ChiCTR2000031364Registration site: http://www.chictr.org/.

Primary orbital monophasic synovial sarcoma with calcification: A case report

BACKGROUND

Synovial sarcoma is a malignant mesenchymal neoplasm with variable epithelial differentiation. Most synovial sarcoma cases are reported in young adults and can arise in any body site. Notably, primary orbital synovial sarcoma is rare.

CASE SUMMARY

An 8-year-old east Asian girl with 1-month history of gradual painless proptosis and lacrimation of the right eye was admitted. The patient presented with painless proptosis, downward eyeball displacement, and upward movement disorders. According to clinical manifestations, imaging examinations and postoperative immunohistochemical examinations, the diagnosis was monophasic synovial sarcoma with calcification. The patient underwent anterior orbitotomy procedure for removal of the right orbital mass under general anesthesia. The diagnosis of monophasic synovial sarcoma with calcification was confirmed finally through histological and immunohistochemical exam. The follow-up period was 6 mo, and no recurrence was observed during this period.

CONCLUSION

Primary orbital monophasic synovial sarcoma with calcification is a rare sarcoma, and clinical manifestations and imaging results are not specific. The tumor may present similar features as a benign tumor. Comprehensive analysis of clinical, radiological, and pathological findings is critically important for making the right diagnosis. Conventional treatment approach for synovial sarcoma is surgical resection with adjuvant or neoadjuvant radiotherapy, which is highly effective for localized tumors.

Hammered silver appearance of the corneal endothelium in Fuchs uveitis syndrome: A case report

BACKGROUND

Hammered silver appearance of the corneal endothelium is considered a characteristic change in iridocorneal-endothelial syndrome. Herein we report an interesting case of hammered silver appearance of the corneal endothelium in Fuchs uveitis syndrome (FUS).

CASE SUMMARY

A 49-year-old man with progressive vision loss in the right eye for one year was admitted to our hospital. The clinical manifestations of the patient's right eye were mild conjunctival hyperemia, scattered stellate keratic precipitates on the corneal endothelium, normal depth anterior chamber, 2+ cellular reaction in the aqueous humor, diffuse iris depigmentation, absence of synechia, Koeppe nodules, opalescent lens, and vitreous opacity. FUS and a complicated cataract were diagnosed based on the typical clinical manifestations. The corneal endothelial changes were recorded in detail by slit-lamp examination, specular microscopy, and in vivo confocal microscopy before cataract extraction, revealing a hammered silver appearance of the corneal endothelium in the affected eye, a wide-band dark area, as well as irregular corneal endothelial protuberances and dark bodies of various sizes. Subsequently, the patient underwent phacoemulsification combined with intraocular lens implantation, and his postoperative visual acuity recovered to 1.0.

CONCLUSION

Hammered silver appearance of the corneal endothelium in FUS, which is considered a more serious manifestation of endothelial damage, is rare and may be caused by many irregular protrusions in the corneal endothelium.

Melanotic neuroectodermal tumor of infancy: A narrative review of dental aspects

Melanotic neuroectodermal tumors of infancy (MNTI) are a rare type of benign tumor that affects the head and neck region. MNTI represents (68-80%) of the tumors in the maxillary region. This tumor is usually located in the alveolar crest, skull, mandible, and brain. Although this tumor is considered benign, it can grow rapidly, with a high risk of recurrence and interference with functions of infancy, such as feeding and breathing. It is also frequently harmful to the surrounding soft and hard tissues or adjacent sensitive vital structures. This study aimed to review the pathological, clinical presentation, and treatment of melanotic neuroectodermal tumors in infancy and the role of dentists in these cases.

Langerhans cell histiocytosis mimicking hematoma of the lower eyelid: A case report

RATIONALE

The orbital Langerhans cell histiocytosis (LCH) is rare clinically, due to its ability to mimic other conditions, distinguishing LCH from hematoma when these disorders coexist can be particularly challenging.

PATIENT CONCERNS

A 3-year-old boy presented with a 2-week history of unresolved bruising and swelling of the left eye. CT revealed a well-defined cystic lesion in the preseptal tissues of the left eyelid, with an incomplete bone structure at the lower margin of the orbit. MRI revealed a well-circumscribed circular mass in the lower margin of the orbit, and a second lesion under the hematoma.

DIAGNOSIS

Postoperative histological examination revealed a diagnosis of LCH with concurrent hematoma.

INTERVENTIONS

The lesions in the left eye were surgically removed through a lower eyelid skin incision under general anesthesia. The patient received 6 courses of systemic chemotherapy, consisting of a combination of vinblastine and prednisolone.

OUTCOMES

No recurrence was observed after a follow-up period of 11 months.

LESSONS

LCH rarely occurs at the infraorbital margin. When external factors, lead to local bleeding and hematoma formation, the presence of lesions may be masked, resulting in a missed diagnosis. Radiographic features such as localized "worm-eaten" bone destruction should not be overlooked for timely LCH diagnosis and treatment.

Spontaneous Blinking Kinematics After Frontalis Muscle Flap Advancement

PURPOSE

To measure the spontaneous blinking metrics after blepharoptosis correction with frontalis muscle flap advancement.

METHODS

A video system was employed to measure the amplitude and velocity of spontaneous blinking of 24 eyelids after the frontalis muscle flap surgery for blepharoptosis correction. A control group with no eyelid disorders was also measured. The data of 13 eyelids who had frontalis slings with autogenous fascia, which were previously collected with the same method in another study, were used for comparison. Digital images were used to measure the superior margin reflex distance and the presence of lagophthalmos during a gentle closure of the palpebral fissure. Superficial keratitis was assessed by corneal biomicroscopy.

RESULTS

The mean amplitude of spontaneous blinking was 6.3 mm in controls, 2.6 mm in the frontalis flap patients, and 2.1 mm in the fascia sling group. The mean blink velocity was 133.8 mm/second in controls, 39.0 mm/second (3.7 standard error) after the frontalis flap, and 36.3 mm/second in patients with frontalis sling with fascia. For these 2 parameters, there was no statistical difference between the surgical groups, but a significant reduction when compared with the control group. No significant association was found between lagophthalmos and keratitis and the surgical procedure.

CONCLUSIONS

There is no difference between the blinking metrics of eyelids operated using the frontalis muscle flap advancement technique or frontalis sling with autogenous fascia. The presence of lagophthalmos and keratitis also does not differ between the 2 procedures.

[Orbital melanotic neuroectodermal tumor in an infant]

A 3-month-old infant patient presented with a 1-week history of a quickly progressive mass in the left eye. A hard, irregularly shaped tumor was found in the superolateral orbit. B-scan showed an uneven hypoecho and an undefined lesion. On the orbital CT, a soft tissue mass was located around the left zygomatic tubercle, involving part of the bone and lacrimal gland. The left orbital mass was removed under general anesthesia after admission. The histological and immunohistochemical examination revealed it was a melanotic neuroectodermal tumor. The infant patient was followed up for 6 months after the operation, and no recurrence was found. (Chin J Ophthalmol, 2021, 57: 372-374).

Primary orbital monophasic synovial sarcoma with calcification: A case report

BACKGROUND

Synovial sarcoma is a malignant mesenchymal neoplasm with variable epithelial differentiation. Most synovial sarcoma cases are reported in young adults and can arise in any body site. Notably, primary orbital synovial sarcoma is rare.

CASE SUMMARY

An 8-year-old east Asian girl with 1-month history of gradual painless proptosis and lacrimation of the right eye was admitted. The patient presented with painless proptosis, downward eyeball displacement, and upward movement disorders. According to clinical manifestations, imaging examinations and postoperative immunohistochemical examinations, the diagnosis was monophasic synovial sarcoma with calcification. The patient underwent anterior orbitotomy procedure for removal of the right orbital mass under general anesthesia. The diagnosis of monophasic synovial sarcoma with calcification was confirmed finally through histological and immunohistochemical exam. The follow-up period was 6 mo, and no recurrence was observed during this period.

CONCLUSION

Primary orbital monophasic synovial sarcoma with calcification is a rare sarcoma, and clinical manifestations and imaging results are not specific. The tumor may present similar features as a benign tumor. Comprehensive analysis of clinical, radiological, and pathological findings is critically important for making the right diagnosis. Conventional treatment approach for synovial sarcoma is surgical resection with adjuvant or neoadjuvant radiotherapy, which is highly effective for localized tumors.

Secondary glaucoma with anterior chamber cholesterolosis: Case series

RATIONALE

The presence of cholesterol crystals in the anterior chamber is extremely rare, and secondary glaucoma with cholesterol crystals in the anterior chamber, reported in the literature, is even rarer. This paper reports 3 cases of secondary glaucoma with cholesterol crystals in the anterior chamber.

PATIENT CONCERNS

Three patients were admitted to the hospital because of ocular distension and blindness. Ocular examination on admission indicated high intraocular pressure, and crystalline gold substances were observed in the anterior chamber.

DIAGNOSIS

Based on clinical manifestations and an aqueous fluid smear, absolute glaucoma and anterior chamber cholesterol crystals were diagnosed.

INTERVENTIONS

In the first case, transscleral ciliary photocoagulation was performed; in the last 2 cases, trabeculectomy combined with extracapsular cataract extraction was performed.

OUTCOMES

The follow-up period was 11 to 15 months. Intraocular pressure was stable in 2 patients treated with surgery, and no cholesterol crystals were observed in the anterior chamber. The intraocular pressure increased in 1 patient treated with laser, and a small amount of cholesterol crystals was still observed in the anterior chamber.

LESSONS

Anterior chamber cholesterol crystallization is extremely rare and cannot be treated if it does not cause other lesions. However, glaucoma occurred in all 3 cases in this study, and intraocular pressure increased in 1 case after laser treatment and remained stable in 2 cases after surgical treatment. Therefore, the treatment plan for anterior chamber cholesterol crystallization in glaucoma requires further discussion.

Severe unilateral congenital ptosis with poor levator function: tarsoconjunctival mullerectomy plus levator resection vs frontalis sling procedure

AIM

To compare frontalis sling and tarsoconjunctival mullerectomy plus levator resection (TCMLR) in subjects with severe unilateral congenital ptosis with poor levator function (LF).

METHODS

A prospective non-randomized non-blinded single center clinical trial. Fifty patients with severe unilateral congenital ptosis with poor LF were recruited. The frontalis sling and TCMLR were performed and the functional, cosmetic outcomes, complications, and success rate were evaluated at 1, 3, and 6mo postoperatively. The t-test, Chi-square, Fishers exact, and nonparametric Mann-Whitney tests were used by SPSS software.

RESULTS

Frontalis sling and TCMLR procedures were performed on 26 and 24 patients respectively. The mean age was 10.97±10.67y. LF was significantly better in the TCMLR group at months 1, 3, and 6 (P=0.002). Lagophthalmos was more common in the TCMLR group (no significant difference). At month 3, mild punctate epithelial erosions were observed more in the frontalis sling group (P=0.002). Significant complete success rate of 1st and 6th month for the frontalis sling vs TCMLR groups were 50% vs 20.8% (P=0.02), and 38.4% vs 50% (P=0.03) respectively.

CONCLUSION

Complete success rate of TCMLR is higher in long-term follow-up in contrast with the frontalis sling in the short-term. Transient complications are more detected in mid-term follow-ups in both groups.

Experience in the treatment of giant orbital intraconal teratoma: A case report

RATIONALE

Orbital teratoma is a relatively rare disease in infancy. In the pediatric population undergoing significant growth and development, the presence of giant orbital masses can significantly affect orbital volumes and impair the visual function. Traditional treatments may not yield anticipated effectiveness, often leading to numerous complications. This report aims to present a rare case involving a giant orbital intraconal teratoma. The objective is to analyze the treatment course comprehensively, distill valuable experiences and lessons learned, enhance treatment strategies, and ultimately reduce the incidence of complications associated with these formidable pediatric tumors.

PATIENT CONCERNS

A 2-year-old female child was presented exhibiting proptosis and inward and upward eyeball displacement. Enhanced magnetic resonance imaging revealed a well-circumscribed mass, persisting with hypointense signals on T1-weighted images (T1WI) and hyperintense signals on T2-weighted images (T2WI).

DIAGNOSES

The diagnosis of teratoma was confirmed finally through histological and immunohistochemical exams.

INTERVENTIONS

A transconjunctival approach via the inferior fornix, coupled with canthotomy and cantholysis, was performed. However, a month postsurgery, the patient developed enophthalmos, conjunctival hyperemia, and keratitis upon ocular examination. A second operation involved the implantation of allogeneic sclera into the orbit to increase orbital volume, improve the pitting of the fossa, and restore keratitis to normal.

OUTCOMES

No recurrence and other complications were noted during the 1-year follow-up.

LESSONS

Giant orbital teratomas in children are infrequent and pose significant challenges in the field of therapy. The potential consequences of larger orbital masses in childhood, including increased orbital volume and the risk of postoperative enophthalmos and keratitis. The findings emphasize the importance of timely implantation into the orbital after mass excision to enhance orbital volume and reduce the incidence of complications.

Isolated cavernous venous malformation of the eyelid

Cavernous hemangioma, currently known as "cavernous venous malformation," is a common, benign, non-infiltrative, slowly progressive vascular malformation of the orbit presenting in adults. We report the case of a 9-year-old girl who presented with a painless palpable mass over the right upper eyelid of 7 years' duration. A computed tomography scan of the orbits revealed a heterogeneously enhancing, well-circumscribed mass in the right upper eyelid with no orbital extension. A transcutaneous excisional biopsy with histopathology disclosed cavernous venous malformation. The majority of cavernous venous malformations are intraconal and present in the fourth to fifth decade of life.

Orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles: report of two cases

BACKGROUND

Two cases of orbitofrontal cholesterol granuloma masquerading as frontal sinus mucoceles were reported to understand image findings, clinical and histopathologic features of orbitofrontal cholesterol granuloma to improve its diagnosis and treatment.

CASE PRESENTATION

Two East Asian patients aged 41 and 27 without personal or familial medical or trauma history presented with the common complaint of proptosis and inferomedial displacement of the eyeballs. The computed tomography (CT) of both cases showed an irregularly shaped, well-defined lesion in the left frontal bone associated with bony erosion. The lesions resulted in the bone absorption of frontal bone and orbital roof, which extended into the superior orbital space. Anterior orbitotomy through subbrow incision by drainage and curettage resulted in a curative outcome. The histopathological examination revealed inflammatory granulation tissues, fibrous capsule wall, cholesterol clefts with altered blood pigments, and calcifications, consistent with the diagnosis of cholesterol granuloma. No recurrence was observed for one year after surgery in one case and three years in the other.

CONCLUSIONS

When the following features are observed: orbital CT exhibits cystic lesion with irregular bone destruction in the superolateral orbit, magnetic resonance imaging (MRI) depicts lesions are hyperintense signals on T1 weighted images (T1WI), and T2 weighted images (T2WI), and the contrast-enhanced imaging reveals that the most of tumor is showed a non-significant enhancement, orbitofrontal cholesterol granuloma should be considered.

A case report of phacolytic glaucoma in lens cortex behind posterior capsule: A CARE-compliant article

RATIONALE

Phacolytic glaucoma (PLG), a secondary open-angle glaucoma caused by high molecular weight proteins leaking through the capsule of a hypermature cataract. Leakage of liquefied lens cortex behind the posterior capsule is rare. In this paper, we review a case of phacolytic glaucoma in the lens cortex behind posterior capsule.

PATIENT CONCERNS

This case report describes a 79-year-old male patient with a 7-year history of progressive blurred vision and a 1-day history of distended in his left eye. He underwent phacoemulsification combined with intraocular lens implantation at our facility 7 years ago.

DIAGNOSES

The patient had lower vision (light perception vision) and increased intraocular pressure (IOP) (60 mmHg) in the left eye. Auxiliary inspection found that the left eye had deep anterior chamber depth (around 1 corneal thickness of the peripheral AC angle) as well as vitreous and aqueous humor opacity in the left eye. Combining the clinical symptoms and examinations, we made the diagnosis of PLG in the left eye.

INTERVENTIONS

The patient underwent trabeculectomy and extracapsular cataract extraction of the left after a stable ocular condition, during the operation to see that white chyous cortex was visible under the posterior capsule and posterior capsule membrane of the lens was avulsed circularly.

OUTCOMES

The postoperative condition was stable. During the follow up of 3 months, the IOP of the left eye was stable without ocular discomfort.

LESSONS

This case reported a patient with phacolytic glaucoma in the lens cortex behind posterior capsule who underwent successful surgery, indicating spontaneous capsule rupture can occur in the posterior capsules in PLG and when this situation is detected during the operation, the posterior capsule tearing method can be applied to absorb the lens cortex sticking at the posterior surface of the posterior capsule.

Extended Frontalis Muscle Advancement Technique for Severe Congenital Blepharoptosis

BACKGROUND

The conventional frontalis muscle advancement technique still has some disadvantages, such as residual lagophthalmos, eyebrow ptosis, eyelid contour abnormality, and undercorrection. This article describes the authors' extended frontalis muscle advancement technique, which takes extensive subcutaneous separation through the eyelid crease incision for the treatment of severe congenital blepharoptosis.

METHODS

A retrospective review was performed that included patients with severe congenital ptosis who underwent extended frontalis muscle advancement technique from April of 2019 to April of 2021. Preoperative evaluation included age, sex, and margin reflex distance 1, levator function, and lagophthalmos. Postoperative evaluation including correction result, closure function of eyelid, and cosmetic result was performed at the last follow-up.

RESULTS

From April of 2019 to April of 2021, a total of 102 patients (137 eyes) who underwent extended frontalis muscle advancement technique were included in the study. The mean postoperative margin reflex distance 1 in unilateral and bilateral ptosis patients was 3.84 ± 0.60 mm and 3.86 ± 0.56, respectively, and 126 eyes (92.0%) showed successful correction. Postoperatively, the mean residual lagophthalmos was 0.88 ± 1.40 mm, and 127 eyes (92.7%) showed excellent or good eyelid closure function. The average score of cosmetic results was 8.29 ± 1.34, and 94 patients (92.2%) had an excellent or good cosmetic result.

CONCLUSIONS

Extensive subcutaneous separation relieves the mutual restriction between the forehead skin and frontalis muscle. The extended frontalis muscle advancement technique is effective in correcting severe congenital ptosis, and minimizes undercorrection, residual lagophthalmos, eyelid contour abnormality, and eyebrow ptosis.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Surgical treatment of orbital tumors in a single center: Analysis and results

BACKGROUND

Orbital tumors, arising within the bony orbit and its contents, present diverse challenges due to their varied origins and complex anatomical context. These tumors, classified as primary, secondary, or metastatic, are further subdivided into intraconal and extraconal based on their relationship with the muscle cone. This classification significantly influences surgical approach and management. This study highlights surgical experiences with orbital tumors, underscoring the importance of tailored surgical approaches based on the lesion's site and its proximity to the optic nerve.

METHODS

This retrospective study at the National Institute of Cancer's Head and Neck Department (2005-2014) analyzed 29 patients with orbital tumors treated with surgery, radiotherapy, chemotherapy, or combinations of them. Patient demographics, tumor characteristics, and treatment responses were evaluated using computed tomography (CT), magnetic resonance imaging, and positron emission tomography-CT imaging. Malignant tumors often required orbital exenteration and reconstruction, highlighting the study's commitment to advancing orbital tumor treatment.

RESULTS

29 patients (18 females and 11 males, age 18-88 years, mean 53.5 years) with orbital tumors exhibited symptoms such as decreased vision and exophthalmos. Tumors included primary lesions like choroidal melanoma and secondary types like epidermoid carcinoma. Treatments varied, involving a multidisciplinary team for surgical approaches like exenteration, with follow-up from 1 to 9 years. Radiotherapy and chemotherapy were used for specific cases.

CONCLUSION

Our study underscores the need for a multidisciplinary approach in treating orbital tumors, involving various surgical specialists and advanced technologies like neuronavigation for tailored treatment. The integration of surgery with radiotherapy and chemotherapy highlights the effectiveness of multidimensional treatment strategies.

Orbital schwannoma with calcification treated by intracapsular excision: A case report

RATIONALE

Orbital schwannoma is a relatively rare orbital tumor, and calcification of the lesion is rarely found in the orbit. We report a case of orbital schwannoma which was characterized by calcification in the orbital muscle cone, and was cured by intracapsular excision.

PATIENT CONCERNS

A 54-year-old female with a complaint of a mass in the left orbit during a magnetic resonance imaging examination and symptom of dizziness 6 months before, presented with painless exophthalmos and vision decline in the left eye.

DIAGNOSES

According to clinical manifestations, imaging examinations and postoperative immunohistochemical examinations, the diagnosis was orbital schwannoma, with calcification in the muscle cone.

INTERVENTIONS

The patient was treated by intracapsular excision of the left orbit. We removed the intracapsular mass and most part of the cyst wall in order to prevent orbital apex syndrome.

OUTCOMES

The diagnosis of schwannoma with calcification was confirmed finally through histological and immunohistochemical exam. The patient was followed up for 28 months and the orbital CT scan showed that there were no significant lesions found in the orbital muscle cone.

LESSONS

Understanding clinical, imaging diagnostic, and histopathological features of rare orbital schwannoma with calcification will facilitate timely diagnosis and treatment of this condition. The intracapsular excision can help in avoiding complications.

Clinical characteristics and prognosis of orbital solitary fibrous tumor in patients from a Chinese tertiary eye hospital

BACKGROUND

Solitary fibrous tumor (SFT) is predominant within the pleura but very rare in the orbit, which is why the diagnosis of orbital SFT poses challenges in clinical practice. Accordingly, an integrated approach that incorporates specific clinical features, histological, histopathological, and immunohistochemical (IHC) examinations, and molecular analyses is warranted.

AIM

To retrospectively explore the clinical and imaging characteristics, treatment, outcomes of a series of patients with orbital SFT.

METHODS

We conducted a retrospective review of a series of patients diagnosed with a histopathologic orbital SFT treated at a single institution. All data on demogra/phics, clinical characteristics, imaging, treatment, postoperative histopathological and IHC examinations, and prognosis were collected.

RESULTS

In total, 13 patients were enrolled, 7 (53.8%) of whom had the tumor located in the superomedial quadrant of the orbit. Computed tomography revealed a solitary ovoid lesion in 10 (76.9%) patients and irregular lesion in 3 (23.1%) patients. Magnetic resonance imaging results were as follows: On T1 weighted images, 3 (23.1%) patients had hypointense mixed signals, whereas 10 (76.9%) patients showed isointense mixed signals; on T2 weighted images (T2WI), 3 (23.1%), 4 (30.8%), and 6 (46.2%) patients exhibited hypointense mixed, isointense mixed, and hyperintense signals, respectively. Notably, 12 (92.3%) patients showed significant enhancement, whereas there were patchy slightly enhanced areas in the tumor. All patients were treated by surgery. IHC analysis demonstrated that the tumor cells were immunoreactive for CD34, CD99, STAT-6, and vimentin in all patients. The lesions showed Ki-67 positivity < 5% in 1 (7.7) patient, 5%-10% in 10 (76.9%), and > 10% in 2 (15.4%). Two (15.4%) patients exhibited tumor recurrence.

CONCLUSION

The clinical manifestations and radiologic characteristics of orbital SFT are diverse and not specific. Accurate diagnosis and treatment require detailed radiological and histopathological/IHC evaluation.