Distribution and Clinical Characteristics of Periorbital Infantile Hemangiomas

Background: Periorbital infantile hemangiomas (POIHs) are associated with a high incidence of visual complications. Objective(s): To analyze the sites of predilection of POIHs and to determine whether certain sites require earlier intervention due to their higher rate of visual complications. Methods: A retrospective case series study was conducted on patients from two tertiary care centers for 25 years. The location of POIHs was determined from clinical photographs, medical records, and radiological studies. The presence or absence of anisometropic astigmatism (anisoastigmatism) and amblyopia was recorded. Data were analyzed using a chi-square test. Results: There were 486 patients, of which 302 patients had ophthalmology evaluations and 245 patients had refractive error data. At presentation, 10% of patients already had amblyopia and 44% had anisoastigmatism. Medial eyelid lesions had the highest risk of developing anisoastigmatism (anisoastigmatism correlates with eyelid position, p = 0.0001). Segmental and upper medial lesions had the highest risk of amblyopia at initial evaluation. Conclusion: The site of POIH is an important indicator for developing clinically significant anisoastigmatism and amblyopia, underlining the need for early ophthalmologic assessment and management.

111 THE INFLUENCE OF THE ANDAGO® ON GAIT PARAMETERS AMONG OLDER ADULTS IN THE POST-ACUTE REHABILITATION SETTING: A PILOT STUDY

Background

Electromechanical devices incorporating body-weight support have been developed to enable a repetitive approach to gait rehabilitation whilst decreasing physical strain on treating therapists. The Andago® gait trainer provides dynamic body weight support for individuals while simultaneously enabling them to walk overground. The purpose of this study was to compare the effect of the Andago® versus conventional overground walking on gait parameters, fear of falling (FOF) and ratings of perceived exertion in a post-acute rehabilitation population.

Methods

Patients undergoing rehabilitation were randomly assigned to the Andago® or conventional walking condition on day one with the alternate testing condition completed on day two. Participants completed a 10-metre walk test where stride length, walking speed and cadence were recorded. Participants then undertook a 20-minute gait re-education session where number of steps, distance walked and number of siting breaks were recorded. Ratings of perceived exertion (BORG) and FOF scores were recorded at minutes 1, 10 and 20.

Results

Twenty-seven participants (mean age 78 (SD 9.2), female 55.6%(n=15)) completed the study. Reasons for rehabilitation included neurological (51.8%; n= 14), orthopaedic (33.3%; n=9) and medical conditions (14.8%; n=4). Forty-four percent of participants (n=12) had a mild cognitive impairment. Body weight support ranged from 10% to 17% (mean 11%, SD 2). No significant differences in the 10-metre walk test were found between conditions. A reduction in the number of sitting breaks (p <0.05) and FOF at minutes 10 (p<0.05) and 20 (p<0.05) was found in favour of the Andago® during the gait re-education session.

Conclusion

Preliminary results suggest the Andago® is a feasible modality for gait re-education in patients undergoing rehabilitation, being at least comparable to conventional overground gait training. A reduction in FOF in patients coupled with decreased physical strain on therapists may provide opportunities for more intensive practice and warrants further investigation.

The Ophthalmology Surgical Competency Assessment Rubric (OSCAR) for anterior approach ptosis surgery

PURPOSE

The International Council of Ophthalmology (ICO) is currently developing a series of standardized, internationally validated, teaching tools for key ophthalmic surgical procedures called the Ophthalmology Surgical Competency Assessment Rubrics (OSCARs). This study aims to develop an OSCAR for anterior approach ptosis surgery.

METHODS

An international panel of content experts, representing Australia, India, Iran, Italy, Turkey, UK, and the USA was established and worked to develop the rubric using a range of online collaboration tools. The team used the standardised OSCAR template as a baseline, developing explicit behavioural descriptors (the behaviour and performance expected for each step) that were reviewed and modified with successive models. Learners were scored a modified 4-point Dreyfus scale of skill acquisition (novice, beginner, advanced beginner, competent) with the removal of the expert domain.

RESULTS

The final OSCAR ptosis tool was developed in alignment with the ICO-OSCAR standard. Seventeen agreed and weighted stems were produced. Domains such as communication and postoperative complications were removed from this rubric as they are evaluated in other spheres of residency training. Specific comments with regard to the parameters and wording were incorporated to formulate the final rubric, which was internationally agreed and demonstrated face and content validity.

CONCLUSIONS

The OSCAR for anterior approach ptosis is skill and behaviour-based, has ICO agreed standards for assessment and provides learners with specific targets for improvement. Although the OSCAR ptosis tool has face and content validity, further development could better elucidate its precise role.

Management of Long-Standing Flaccid Facial Palsy: Periocular Considerations

Ineffective eyelid closure can pose a serious risk of injury to the ocular surface and eye. In cases of eyelid paresis, systematic examination of the eye and ocular adnexa will direct appropriate interventions. Specifically, 4 distinct periorbital regions should be independently assessed: eyebrow, upper eyelid, ocular surface, and lower eyelid. Corneal exposure can lead to dehydration, thinning, scarring, infection, perforation, and blindness. Long-term sequelae following facial nerve palsy may also include epiphora, gustatory lacrimation, and synkinesis.

Investigation of goldmann perimetry in evaluation of patients for upper eyelid blepharoplasty

PURPOSE

To determine if preoperative Goldmann Visual Field (GVF) testing in patients with functional dermatochalasis accurately depicts the postoperative superior visual field (SVF) outcome.

METHODS

A prospective cohort study was done to compare preoperative and postoperative GVF field tests in patients undergoing upper eyelid blepharoplasty for treatment of dermatochalasis. This study was conducted in accordance with the Declaration of Helsinki and approved by the University of Arkansas for Medical Sciences institutional review board. A preoperative GVF was obtained with the eyelids in the natural position (untaped) and then again with excess skin elevated (taped). One month post-blepharoplasty, another GVF was conducted with eyelids untaped. The pre- and post GVF tests were analyzed to determine if preoperative testing accurately predicts the SVF improvement post-blepharoplasty.

RESULTS

Forty-six eyelids (23 patients) who underwent blepharoplasty for dermatochalasis were included. The preoperative testing underestimated 76% (35/46) of cases by a mean of 61%; and overestimated the final outcome in 24% (11/46) of cases by mean of 23%. Overall, the preoperative GVF testing underestimated the postoperative outcome by a mean of 35%.

CONCLUSION

Improvement of the SVF after a blepharoplasty is typically greater than the preoperative GVF testing predicts.

Lymphatic malformation with acquired Horner syndrome in an infant

An infant presented with right upper eyelid ptosis and was subsequently diagnosed with acquired Horner syndrome. Further evaluation revealed a right-sided cervicothoracic lymphatic malformation. At 13 weeks of age, the child underwent percutaneous intracystic sclerotherapy with a mixture of sodium tetradecyl sulphate and ethanol. Twenty-one weeks after initial treatment, ophthalmic examination showed complete resolution of the blepharoptosis and pupillary miosis. Percutaneous sclerotherapy not only effectively treated the space-occupying lymphatic malformation but also reversed the Horner syndrome that was presumably induced by neural tension (more likely) or compression.

Lymphatic malformation with acquired Horner syndrome in an infant

An infantpresented with right upper eyelid ptosis and was subsequently diagnosed with acquired Horner syndrome. Further evaluation revealed a right-sided cervicothoracic lymphatic malformation. At 13 weeks of age, the child underwent percutaneous intracystic sclerotherapy with a mixture of sodium tetradecyl sulphate and ethanol. Twenty-one weeks after initial treatment, ophthalmic examination showed complete resolution of the blepharoptosis and pupillary miosis. Percutaneous sclerotherapy not only effectively treated the space-occupying lymphatic malformation but also reversed the Horner syndrome that was presumably induced by neural tension (more likely) or compression.

Clinicopathologic and Magnetic Resonance Imaging Analysis of a Multifocal Orbital Lymphoid Tumor

Objective

To distinguish between a multifocal orbital lymphoid tumor and a major simulator represented by a diffuse lymphaticovenous malformation.

Methods

We performed a comparison of clinical and radiographic (magnetic resonance imaging [MRI]) findings of these two disparate entities and demonstrated how a misdiagnosis can be prevented.

Results

Orbital lymphoid tumors develop in adults at around 60 years of age, whereas extensive lymphaticovenous malformations are generally detected in the first decade. Despite these differences, this is the first description of clinical confusion between them. MRI with gadolinium injection in the current lymphoid tumor displayed a low signal on T2-weighted images, rapid and uniform enhancement, and reduced diffusion. Lymphaticovenous malformations are heterogeneous, display poor or only focal perfusion, and fail to exhibit diminished diffusion. Newer techniques such as diffusion-weighted imaging and dynamic contrast-enhanced imaging may be able to provide additional differential diagnostic information. The final pathologic diagnosis was an extranodal marginal zone lymphoma.

Conclusions

Despite the obvious distinctions between orbital lymphoid tumors and lymphaticovenous malformations, several clinical radiologic specialists misdiagnosed the present orbital lesion as a vascular lesion. A combined clinicoradiographic analysis should obviate such errors and facilitate the correct diagnosis in the future.

Consensus on Diagnostic Criteria of Idiopathic Orbital Inflammation Using a Modified Delphi Approach

Importance

Current practice to diagnose idiopathic orbital inflammation (IOI) is inconsistent, leading to frequent misdiagnosis of other orbital entities, including cancer. By specifying criteria, diagnosis of orbital inflammation will be improved.

Objective

To define a set of criteria specific for the diagnosis of IOI.

Design, Setting, and Participants

A 3-round modified Delphi process with an expert panel was conducted from June 8, 2015, to January 25, 2016. Fifty-three orbital scientist experts, identified through membership in the Orbital Society, were invited to participate in on online survey and they scored, using 5-point Likert scales, items that are eligible as diagnostic criteria from the literature and from personal experience. The items were clustered around the anatomic subtypes of IOI: idiopathic dacryoadenitis and idiopathic orbital fat inflammation (2 nonmyositic IOIs), and idiopathic orbital myositis (myositic IOI). Items with dissensus were rescored in the second round, and all items with consensus (median, ≥4; interquartile range, ≤1) were ranked by importance in the third round.

Main Outcomes and Measures

Consensus on items to be included in the criteria.

Results

Of the 53 experts invited to participate, a multinational panel of 35 (66%) individuals with a mean (SD) years of experience of 31 (11) years were included. Consensus was achieved on 7 of 14 clinical and radiologic items and 5 of 7 pathologic items related to diagnosis of nonmyositic IOI, and 11 of 14 clinical and radiologic items and 1 of 5 pathologic items for myositic IOI. There was agreement among panelists to focus on surgical tissue biopsy results in the diagnosis of nonmyositic IOI and on a trial with systemic corticosteroids in myositic IOI. Panelists agreed that a maximum number of 30 IgG4-positive plasma cells per high-power field in the orbital tissue is compatible with the diagnosis of IOI.

Conclusions and Relevance

An international panel of experts endorsed consensus diagnostic criteria of IOI. These criteria define a level of exclusion suggested for diagnosis and include tissue biopsy for lesions not confined to the extraocular muscles. This consensus is a step toward developing guidelines for the management of IOI, which needs to be followed by validation studies of the criteria.

One-Stage Supramaximal Full-Thickness Wedge Resection of Vascular Lip Anomalies

PURPOSE

Vascular lip anomalies include infantile hemangiomas, venous malformations, and arteriovenous malformations. Surgical management can be complicated by alterations in horizontal length, vertical height, and lip thickness from the underlying pathology. Additional reconstructive challenges include preservation of oral continence, vermillion definition, and the sublabial sulcus. This report describes a technique of supramaximal single-stage full-thickness wedge resection of these lesions.

MATERIALS AND METHODS

A retrospective study approved by the institutional review board of patients who underwent full-thickness resection of vascular lip anomalies from December 2007 through February 2013 was performed. Patient demographics, final diagnosis, preoperative treatment, examination findings (pre- and postoperative), intraoperative management, and follow-up findings were reviewed.

RESULTS

Eighteen patients (9 female) with a mean age of 25 ± 19.8 years (range, 3 to 70 yr) were identified. Underlying pathologies were arteriovenous malformation (6), port wine stain with secondary soft tissue hypertrophy (6), capillary malformation (1), venous malformation (3), and infantile hemangioma (2). Prior treatments included embolization, lasers, surgical excision, steroids, and propranolol; 8 patients were treatment naive. All patients underwent a single or double pentagonal-shaped wedge resection of the involved upper or lower lip. An average of 3.75 cm (41.7%; range, 20 to 70%) of horizontal lip length was excised. Four patients required additional concomitant debulking of the vermillion. No intraoperative complications were noted. Postoperatively, 1 patient developed wound dehiscence at 12 days and another had a midline depression with mild oral incontinence. Follow-up averaged 1,074 days (range, 371 to 1,777 days) and patients and their parents reported a high degree of satisfaction with the improvement in lip appearance and symmetry except for 1 patient who required further debulking. The sublabial sulcus and vermillion and cutaneous definition were preserved in all cases.

CONCLUSION

Despite the traditional recommendation that no more than 30% of lip length be surgically removed, vascular lip anomalies result in tissue hypertrophy, horizontal elongation, ectropion labii, and tissue expansion that allow up to 70% of the lip to be excised.

Orbital exenteration: The 10-year Massachusetts Eye and Ear Infirmary experience

The authors report their experience with orbital exenteration surgery at one academic institution over a 10-year period and review the literature. This retrospective cohort study monitored outcomes of all patients who underwent orbital exenteration surgery at Massachusetts Eye and Ear Infirmary between January 2003 and January 2013. Patients with no follow-up data or survival data were excluded from the study. The main outcome measures were surgical complications, disease status of surgical margins, need for adjuvant treatment, local recurrence, metastases and survival. 23 patients with malignancy and 2 with mucormycosis met inclusion criteria for the study. Surgical procedures included non-lid sparing total exenteration (44%), lid-sparing total exenteration (32%), non-lid sparing partial exenteration (8%) and lid-sparing partial exenteration (16%). 44% underwent additional extra-orbital procedures. Survival rates were 72% at 1 year, 48% at 3 years, and 37% at 5 years. Of patients with malignancies, 48% had clear margins after exenteration. There was no statistically significant difference in survival between patients with negative surgical margins compared to positive margins (p = 0.12). Mortality was highest in patients with melanoma (85.7%) and lowest in patients with non-squamous cell lid malignancies (0%). Our study suggests that the type of disease has a much greater impact on the survival of patients undergoing exenteration surgery than the type of exenteration surgery or the disease status of surgical margins. Patients with non-squamous cell lid malignancies and localized orbital disease have the best prognosis for tumor eradication from this radical and highly disfiguring surgery.

Orbital Decompression in the Endoscopic Age

Objective

Postoperative diplopia occurs in up to 45% of patients following orbital decompression for exophthalmos associated with Graves’ orbitopathy. We sought to describe outcomes of our balanced orbital decompression strategy that includes the preservation of a modified inferomedial orbital strut (mIOS).

Study Design

Case series with chart review.

Setting

Academic medical center.

Subjects and Methods

A total of 115 consecutive orbital decompressions were performed on 73 patients (42 bilateral) with Graves’ orbitopathy. All patients underwent (1) a balanced decompression technique incorporating an endoscopic medial and external lateral decompression and (2) a mIOS technique with preservation of the anterior half of the inferomedial orbital strut. A periorbital periosteal (orbital) sling was utilized in patients (n = 54) without threatened vision loss, proptosis >28 mm, or periorbital disruption to prevent prolapse of the medial rectus muscle.

Results

Utilization of the mIOS technique with or without a sling did not adversely affect the reduction in proptosis (5.1 mm with sling vs 5.0 mm without sling; P = .85).The incidence of new-onset postoperative diplopia was 17% (n = 6). The sling was not associated with postoperative diplopia (odds ratio = 0.54, 95% confidence interval: 0.08-3.40, P = .51), while it was associated with resolution of preexisting diplopia (odds ratio = 6.67, 95% confidence interval: 1.06-42.06, P = .04). No intraoperative complications occurred, and no patients suffered a decrement in visual acuity.

Conclusion

Balanced orbital decompression utilizing a mIOS in patients with Graves’ orbitopathy provides a safe and effective reduction in proptosis with a low rate of new-onset diplopia as compared with historical values. Utilization of an orbital sling may be beneficial in reducing postoperative diplopia in select patients.

Axial Globe Position Measurement: A Prospective Multicenter Study by the International Thyroid Eye Disease Society

PURPOSE

Identify a reproducible measure of axial globe position (AGP) for multicenter studies on patients with thyroid eye disease (TED).

METHODS

This is a prospective, international, multicenter, observational study in which 3 types of AGP evaluation were examined: radiologic, clinical, and photographic. In this study, CT was the modality to which all other methods were compared. CT AGP was measured from an orthogonal line between the anterior lateral orbital rims to the cornea. All CT measurements were made at a single institution by 3 individual clinicians. Clinical evaluation was performed with exophthalmometry. Three clinicians from each clinical site assessed AGP with 3 different exophthalmometers and horizontal palpebral width using a ruler. Each physician made 3 separate measurements with each type of exophthalmometer not in succession. All photographic measurements were made at a single institution. AGP was measured from lateral photographs in which a standard marker was placed at the anterior lateral orbital rim. Horizontal and vertical palpebral fissure were measured from frontal photographs. Three trained readers measured 3 separate times not in succession. Exophthalmometry and photography method validity was assessed by agreement with CT (mean differences calculation, intraclass correlation coefficients [ICCs], Bland-Altman figures). Correlation between palpebral fissure and CT AGP was assessed with Pearson correlation. Intraclinician and interclinician reliability was evaluated using ICCs.

RESULTS

Sixty-eight patients from 7 centers participated. CT mean AGP was 21.37 mm (15.96-28.90 mm) right and 21.22 mm (15.87-28.70 mm) left (ICC 0.996 and 0.995). Exophthalmometry AGP fell between 18 mm and 25 mm. Intraclinician agreement across exophthalmometers was ideal (ICC 0.948-0.983). Agreement between clinicians was greater than 0.85 for all upright exophthalmometry measurements. Photographic mean AGP was 20.47 mm (10.92-30.88 mm) right and 20.30 mm (8.61-28.72 mm) left. Intrareader and interreader agreement was ideal (ICC 0.991-0.989). All exophthalmometers' mean differences from CT ranged between -0.06 mm (±1.36 mm) and 0.54 mm (±1.61 mm); 95% confidence interval fell within 1 mm. Magnitude of AGP did not affect exophthalmometry validity. Oculus best estimated CT AGP but differences from other exophthalmometers were not clinically meaningful in upright measurements. Photographic AGP (right ICC = 0.575, left ICC = 0.355) and palpebral fissure do not agree with CT.

CONCLUSIONS

Upright clinical exophthalmometry accurately estimates CT AGP in TED. AGP measurement was reliably reproduced by the same clinician and between clinicians at multiple institutions using the protocol in this study. These findings allow reliable measurement of AGP that will be of considerable value in future outcome studies.

Invasive fungal disease of the sinus and orbit: a comparison between mucormycosis and Aspergillus

BACKGROUND/AIMS

Invasive fungal infections of the head and neck are rare life-threatening infections where prompt diagnosis and intervention is critical for survival. The aim of this study is to determine the clinical characteristics and outcomes of invasive fungal disease of the sinus and orbit, and to compare mucormycosis and Aspergillus infection.

METHODS

A retrospective review was conducted from a single tertiary care eye and ear hospital over 20 years (1994-2014). Twenty-four patients with a confirmed pathological diagnosis of invasive fungal disease of the sinus and/or orbit were identified and their medical records were reviewed. The main outcome measures were type of fungus, location of disease, mortality and visual outcome.

RESULTS

Patients with orbital involvement had a higher mortality and higher likelihood of mucormycosis infection compared with those with sinus-only disease (78.6% vs 20%, p=0.01; 86% vs 30%, p=0.01, respectively). Patients with mucormycosis had a higher mortality (71%) than patients with Aspergillus (29%); however, this was not statistically significant (p=0.16). All patients with orbital involvement and/or mucormycosis infections were immunosuppressed or had inadequately controlled diabetes, and had a cranial neuropathy or ocular motility dysfunction. All five post-transplant patients with orbital infections died, while the two transplant patients with sinus infections survived.

CONCLUSIONS

Patients with orbital fungal infections are more likely to be infected with mucormycosis compared with Aspergillus and have a higher mortality compared with infections sparing the orbit. History of transplant portends a dismal prognosis in orbital infections. Invasive fungal disease should be considered in any immunocompromised patient presenting with a new cranial neuropathy or ocular motility abnormality.

A Biomechanical Evaluation of Auricular Cartilage Autografts in Orbital Floor Defect Repair

OBJECTIVE

Auricular cartilage is used as a surgical implant in the management of orbital floor fractures. However, no specific parameters exist regarding the use/limitations of this potential graft. In order to determine the mechanical efficacy of adult auricular cartilage grafts, a mechanical model was developed and studied for structural threshold size limits.

METHODS

Thirty-seven cadaveric auricular cartilage specimens were tested in a laboratory. A plexiglass baseplate was created with four different sized holes, defined as 1.0×, 1.2×, 1.4×, and 1.6× the mean minor axis of the specimens. Each specimen was used to bridge one hole under increasing loads until mechanical failure. Structural stiffness at three different loading stages, structural failure strength, and percent failure of the entire system for each defect size was calculated.

RESULTS

Specimens tested on 1.0×, 1.2×, 1.4× and 1.6× defects demonstrated 0%, 0%, 20%, and 60% system failure rates, respectively. Structural stiffness curves showed a similar trend, with ANOVA demonstrating a significant difference in mechanical properties between defect sizes (p = 0.03). The curve representing 1.6 × defect size demonstrated significantly reduced structural stiffness relative to 1.0×, 1.2×, and 1.4× curves. There was no statistical difference between 1.2× and 1.4× testing sets (p = 0.09).

CONCLUSION

A clinically significant biomechanical and functional threshold exists between 1.2×and 1.4× defect sizes. Given a mean minor axis of 2.06 cm, orbital blow-out defects <2.4 cm (1.2 × 2.06 cm) are suitable for auricular cartilage grafts; fractures >2.4 cm may require a more rigid material. Cartilage grafts that allow failure, however, may better protect the globe in subsequent injury.

A clinical, radiologic, and immunopathologic study of five periorbital intraosseous cavernous vascular malformations

PURPOSE

To correlate the clinical, radiographic, histopathologic, and immunohistochemical features of 5 primary periorbital intraosseous cavernous vascular malformations.

DESIGN

Retrospective interventional case series.

METHODS

Clinical and operative records and radiographic images were reviewed. Histopathologic slides were evaluated with hematoxylin-eosin, trichrome, and elastin stains. Immunohistochemical studies were performed with a spectrum of monoclonal antibodies directed at antigens of vascular cells.

RESULTS

Three men and 2 women ranged in age from 36 to 64 years. Vision was unaffected and there was no proptosis or globe displacement. The slow-growing lesions measured 13-25 mm in greatest diameter (mean 16.4 mm). Computed tomographic studies revealed that 2 lesions were situated in the maxillary bone, 2 in the frontal, and 1 in the zygoma, all anteriorly and with circumscribed, lucent, honeycombed, or sunburst characteristics. Histopathologically the lesions were composed of cavernous or telangiectatic channels; 1 showed advanced fibrotic vascular involution. Immunohistochemistry demonstrated CD31/34 positivity for vascular endothelium and D2-40 negativity for lymphatic endothelium. A typically thin mural myofibroblastic cuff was smooth muscle actin positive, weakly calponin positive, and desmin negative. Glucose transporter-1 and Ki-67 were negative in the endothelium.

CONCLUSIONS

Intraosseous vascular lesions resemble orbital cavernous venous malformations (not true hemangiomas), except that their vascular walls are thinner owing to the constraints imposed by neighboring bone spicules, which limit the amount of interstitium from which mural myofibroblasts can be recruited. The bony trabeculae conferred the honeycomb or sunburst appearances observed radiographically. En bloc excision of these lesions was successful and avoided complications (mean follow-up, 46 months).

Niobium-based superconducting nano-device fabrication using all-metal suspended masks

We report a novel method for the fabrication of superconducting nano-devices based on niobium. The well-known difficulties of lithographic patterning of high-quality niobium are overcome by replacing the usual organic resist mask by a metallic one. The quality of the fabrication procedure is demonstrated by the realization and characterization of long and narrow superconducting lines and niobium-gold-niobium proximity SQUIDs.

Dynamic imaging of paralytic eyelid disorders

PURPOSE

Eyelid dysmotility may result from trauma, tumors, inflammation, infection, and a variety of other conditions. In these cases, a mechanical effect is disrupting a normal neuromuscular apparatus. Dysmotility can also be caused by paralytic eyelid disorders; included in this broad category are neurologic and myogenic disorders of eyelid opening and/or closure. Secondary effects include spastic eyelid closure and synkinesis syndromes. These conditions, by definition, are disorders of movement, and can only be studied adequately using dynamic imaging techniques.

METHODS

A comprehensive literature search was performed on PubMed. Ninety abstracts were reviewed.

RESULTS

Dynamic eyelid imaging has evolved dramatically over the past two decades, at least partially due to the rise of inexpensive digital technology. Magnetic search coil imaging, high- and low-speed videography, electromyography, and high-resolution microscopy coil magnetic resonance imaging each has its advantages and disadvantages, an understanding of which will guide appropriate selection of technology in any given clinical situation.

CONCLUSIONS

Dynamic eyelid imaging is useful to study dysmotility. The optimal technique depends upon the clinical setting and the physiologic or pathologic topic of interest. To our knowledge, a report of this type has not been previously summarized.

Changes in gene expression in human meibomian gland dysfunction

PURPOSE

Meibomian gland dysfunction (MGD) may be the leading cause of dry eye syndrome throughout the world. However, the precise mechanism(s) underlying the pathogenesis of this disease is unclear. This study was conducted to identify meibomian gland genes that may promote the development and/or progression of human MGD.

METHODS

Lid tissues were obtained from male and female MGD patients and age-matched controls after eyelid surgeries (e.g., to correct entropion or ectropion). Meibomian glands were isolated and processed for RNA extraction and the analysis of gene expression.

RESULTS

The results show that MGD is associated with significant alterations in the expression of almost 400 genes in the human meibomian gland. The levels of 197 transcripts, including those encoding various small proline-rich proteins and S100 calcium-binding proteins, are significantly increased, whereas the expression of 194 genes, such as claudin 3 and cell adhesion molecule 1, is significantly decreased. These changes, which cannot be accounted for by sex differences, are accompanied by alterations in many gene ontologies (e.g., keratinization, cell cycle, and DNA repair). The findings also show that the human meibomian gland contains several highly expressed genes that are distinct from those in an adjacent tissue (i.e., conjunctival epithelium).

CONCLUSIONS

The results demonstrate that MGD is accompanied by multiple changes in gene expression in the meibomian gland. The nature of these alterations, including the upregulation of genes encoding small proline-rich proteins and S100 calcium-binding proteins, suggest that keratinization plays an important role in the pathogenesis of MGD.

Idiopathic fibroinflammatory disease of the face, eyelids, and periorbital membrane with immunoglobulin G4-positive plasma cells

Progressive sclerosing orbital pseudotumors are a subset of usually primary and localized idiopathic fibroinflammatory disorders. We report on a 66-year-old man who developed this condition along the facial tissue planes with extension into the orbit and preferential involvement of the periorbital membrane. Fibrocollagenous tissue with scattered lymphoid aggregates without follicle formation dominated the process. There was a light dispersion of B and T lymphocytes and histiocytes in the stroma. Immunoglobulin G4 (IgG4)-positive plasma cells (>35 per high-power field) were identified mostly in the lymphoid clusters, as has been discovered in similar IgG4-related fibrosclerosing conditions of other nonorbital sites. No associated systemic disease emerged during a 20-year clinical course. Previously reported orbital cases of IgG4-positive disease have all involved the lacrimal gland, usually bilaterally, and more closely resembled hypercellular reactive lymphoid hyperplasias with moderate interlobular fibrosis, rather than representing an essentially sclerosing process from the beginning.

Quantum dynamics in a camelback potential of a dc SQUID

We investigate a quadratic-quartic anharmonic oscillator formed by a potential well between two potential barriers. We realize this novel potential with a dc SQUID at near-zero current bias and flux bias near half a flux quantum. Escape out of the central well can occur via tunneling through either of the two barriers. We find good agreement with a generalized double-path macroscopic quantum tunneling theory. We also demonstrate an "optimal line" in current and flux bias along which the oscillator, which can be operated as a phase qubit, is insensitive to decoherence due to low-frequency current fluctuations.

Complex palpebral odontogenic choristoma: A reappraisal of the origin of teeth-bearing periocular lesions

PURPOSE

To describe the findings observed in a congenital ectopic tooth of the lower inner eyelid and explain its origin.

DESIGN

Retrospective and interventional clinicopathologic study.

METHODS

Histopathologic evaluation of sequentially excised specimens over 4 years and radiographic study of any associated dental abnormalities, compared with critical reevaluation of similar reported cases in the literature.

RESULTS

The ectopic eyelid tooth clinically created a dome-shaped mass and microscopically displayed advanced cytodifferentiation but incomplete morphogenesis with clearly identifiable ameloblasts, enamel, odontoblasts, and dentin, surrounded by an intact dental sac. Swollen oral mucosal epithelium with associated sebaceous Fordyce nodules, residual ciliated odontogenic epithelium, embryonic epithelial rests, and accessory mucinous and sero-mucinous accessory salivary glands were discovered in place of normal conjunctiva. The tarsus with meibomian glands was absent but islands of cartilage were present.

CONCLUSIONS

Because of the variety of the ectopic tissues that were exhibited, a causative displacement of oral embryonic epithelium with extensive differentiating potentialities is posited. Two previously reported palpebral dental choristomas also had identical locations in the inferomedial eyelid. This is the site where the phakomatous choristoma may be encountered, but this unencapsulated mass creates an eyelid thickening without a globoid configuration and infiltrates the inferior orbit. After a careful re-appraisal of published reports of orbital cysts bearing a tooth that were formerly diagnosed as "teratomas," we have concluded that they developed from similar embryonic oral (buccal) epithelial displacements rather than from aberrant germ cells, based on the cysts' linings and the associated accessory salivary glands in their walls. This view is further supported by the absence of heterologous teratomatous elements of endodermal or neuroectodermal derivation. A clinical and surgical approach to management and a new diagnostic schema for odontogenic choristomas are proposed.