Orbital swelling: a simplified guide

Swelling in and around the orbit is common but many doctors may have difficulty forming a differential diagnosis for an orbital swelling. It is important to be able to differentiate the causes of orbital swelling either because they are common (e.g. thyroid eye disease) or because they are rare (e.g. mucormycosis) but may result in loss of vision or even death (Gamba et al, 1986; Rootman, 2001; Tanaka et al, 2004; Kanski, 2007; Lutt et al, 2008). This article outlines the assessment of orbital swelling.

Isolated Muller's muscle resection for the correction of blepharoptosis

PURPOSE

To assess the outcome of isolated Muller's muscle resection with preservation of conjunctiva in patients with blepharoptosis and good to moderate levator function.

METHODS

This study was designed as a prospective, nonrandomised case series. Thirty-four eyes of 27 blepharoptosis patients were operated on, who were phenylephrine test-negative as well as positive. Open-sky Muller's muscle resection was performed with preservation of the conjunctiva. Main outcome measures were increase in margin reflex distance (MRD1), eyelid contour, and symptoms and signs of dry eye.

RESULTS

The mean increase in MRD1 was 2.75 mm. All but one patient (96%) had upper lid margins resting at or up to 1 mm below the limbus and obtained symmetry to within 0.5 mm of the fellow eye. No patients had symptoms or signs of dry eye.

CONCLUSION

Isolated Muller's muscle resection is effective for the correction of ptosis in patients with moderate to good levator function. This is irrespective of the lid's response to phenylephrine. Preservation of conjunctival tissue eliminates concerns about dry eye, and also preserves the full height of the fornix.

Superficial adnexal lymphangioma

An 11-year old girl presented with a painless fleshy lesion involving the plica, caruncle and medial bulbar and palpebral conjnctiva of the right eye since birth. The patient underwent debulking and cryotherapy. Biopsy showed lymphatic vessels lined with one flattened layer of endothelial cells devoid of smooth muscles or pericytes. Most of the lumens contained pink amorphous lymph with lymphoid aggregates.

Open sky Müller's muscle-conjunctiva resection for ptosis surgery

PURPOSE

We describe a surgical technique for ptosis correction in moderate to good levator function involving resection of Müller's muscle of the upper eyelid. This is a substantial modification of the technique described by Putterman. We then present our experience of and the results from this method.

METHODS

A subtotal resection of Müller's muscle plus underlying conjunctiva is performed under direct visualisation. The muscle stump is reattached to the tarsus and the sutures passed through to the skin crease. In those cases where the phenylephrine test was positive to a level less than the desired lid height, a 1 mm of strip of tarsus is included in the tissue resection. The sutures are removed between 5 days and 3 weeks postoperatively allowing control over lid height and contour. A total of 61 eyes of 48 patients underwent this procedure.

RESULTS

Of 61 eyelids, 56 undergoing this procedure were within 0.5 mm of the desired end point, giving a success rate of 92%. Of 61 eyelids, 60 were within 1 mm of the desired height. Preoperative phenylephrine 10% was highly predictive of postoperative lid height (58/61). An excellent lid contour was noted in all cases (61/61).

CONCLUSIONS

We present a new approach to ptosis correction using Müller's muscle. It has a high success rate and good cosmetic outcome. It is technically straightforward and easy to learn.

External dacryocystorhinostomy for the treatment of acquired partial nasolacrimal obstruction in adults

AIM

To determine the long term success of external dacryocystorhinostomy (DCR) in adults with acquired partial nasolacrimal obstruction.

METHODS

A retrospective study of 50 external dacryocystorhinostomies with silicone intubation performed for partial nasolacrimal obstruction, was undertaken. Preoperative lacrimal scintigraphy divided drainage abnormalities into presac or postsac delays. Postoperative success was determined by lacrimal patency to irrigation, a positive dye test on nasal endoscopy and subjective resolution of epiphora. Statistical analysis was performed using the Fisher exact test.

RESULTS

A patent DCR system to irrigation and a positive dye test was achieved in 90% of procedures. At an average of 3.6 months' follow up, subjective success was reported in 84% of cases-91% for postsac and 67% for presac delays. At 3 years' follow up success had declined to 70% overall and to 80% and 47% for postsac and presac occlusions respectively. There was a statistically significant association between a presac delay and postoperative recurrence of epiphora, p = 0.04.

CONCLUSION

External DCR with silicone intubation is an effective procedure for partial nasolacrimal obstruction. Presac delays do significantly less well and further studies are necessary to evaluate the best type of surgery for these patients.

A case report of Mycobacterium chelonae keratitis and a review of mycobacterial infections of the eye and orbit

Mycobacteria are unusual causes of keratitis and other ocular infections but the outcome of infection is often serious. We report a case of keratitis due to Mycobacterium chelonae, a rapidly growing environmental mycobacterium, in a soft contact-lens wearer, and discuss the difficulty and delay in identifying the organism, twice erroneously identified as Nocardia asteroides on morphological grounds. Despite in vitro susceptibility, the response to anti-bacterial agents was negligible and a second keratoplasty was required after a recurrence of disease at the donor-host junction. We review the role of mycobacteria as the cause of keratitis and other forms of ocular disease.