[Necrotising soft tissue infection of orbital area and hand: an unusual combination]

BACKGROUND

Necrotising soft tissue infection (NSTI) is an infection of the subcutaneous tissues and often follows a fulminant course if not recognised in time.

CASE DESCRIPTION

A 78-year-old man was brought to our emergency department in septic shock. Physical examination revealed an erythematous and painful swelling of the right eyelids and to a lesser extent of the right hand. The infection progressed at both sites, and suspicion of NSTI arose. An emergency surgical debridement was performed. Pathological examination of the excised tissue confirmed the presence of a necrotising infection of the fascia consistent with NSTI at both sites.

CONCLUSION

This case history describes a, not previously described, 'double' presentation of NSTI. In a patient with misunderstood sepsis in combination with a soft tissue infection, it is important to consult a surgeon immediately. This case report emphasises the need for a multidisciplinary approach when treating patients with these clinical pictures.

CONFLICT OF INTEREST AND FINANCIAL SUPPORT

NONE DECLARED.

[Eye lid hygiene in chronic allergic blepharoconjunctivitis patients before laser refractive surgery]

AIM

To evaluate the effectiveness of eyelid hygiene in patients with chronic allergic blepharoconjunctivitis (ABC) as a part of their preparation for laser refractive surgery.

MATERIAL AND METHODS

The study involved 32 patients (12 males and 20 females aged 25-42 years) with refractive errors, namely, compound myopic astigmatism (23 patients) and hyperopic astigmatism (9 patients) suffering from chronic ABC and secondary dry eye syndrome (DES). All the patients initially received a standard treatment for ABC and DES, that is olopatodin hydrochloride instillations - 1 mg/ml 2 times daily, preservative-free hyaluronic acid preparation - 1 mg/ml 3 times daily, and polyacrylic acid and dexpanthenol gel at night for one month. The scheme, however, appeared not effective enough. Hence, the patients were prescribed eyelid hygiene (Blepharolotion or Blepharosalfetka plus Blepharogel-1 2 times daily) to relive meibomian gland dysfunction (MGD). They also underwent a conventional ophthalmic examination, allergy tests, evaluation of ABC and DES signs and symptoms, tear film break-up time test, Schirmer's test, meibomian glands evaluation, optical coherence tomography with meniscometry, xerosis index evaluation, and lissamine green staining for lid wiper epitheliopathy.

RESULTS

At the beginning of the study signs and symptoms of MGD-associated DES were predominant in all patients. Chronic ABC signs were mild. In 2-3 months, meibomian gland function and tear film break-up time improved significantly in most patients, while xerosis index decreased and lid wiper epitheliopathy resolved. Laser refractive surgery (LASIK) was performed in 81.25% of patients, all of whom were satisfied with the results.

CONCLUSION

Inclusion of eyelid hygiene into preoperative management of patients with chronic ABC and DES allows to achieve optimum conditions for laser refractive surgery in most cases.

Chronische Blepharitis

Chronic blepharitis is one of the most common diseases of the eyelids, but surprisingly, it is not often recognized. Frequently, a skin disease such as seborrheic dermatitis, atopic dermatitis, or acne rosacea is the underlying cause of chronic blepharitis. Bacterial pathological lipase, cholesterylesterase production, and bacterial lipopolysaccharides are pathogenetically relevant. Only rarely do genuine bacterial infections play a role. Collarettes occur at the base of the eye lashes, and the Meibomian glands show either abundant fluid secretion or inspissated secretion with obstruction of the orifices. Chronic blepharitis can include sequelae including dry eye and corneal and lid contour changes. The basic treatment comprises attendance of the underlying dermatological disease and lid hygiene. In addition, preservative-free tear film substitutes, antibiotics, immunomodulatory agents, or even surgical intervention may become necessary.

INTRACAPSULAR LENS REMOVAL IN A PRZEWALSKI'S WILD HORSE (EQUUS CABALLUS PRZEWALSKII)

A 11.5-yr-old female Przewalski's wild horse (Equus caballus przewalskii) presented for unilateral blepharitis and drainage from the left eye. The left cornea was not ulcerated, and intraocular evaluation was hampered by severe corneal edema. The left eye appeared to respond positively to treatment with anti-inflammatories and a topical mydriatic agent. During the ensuing 2 yr, there were minor episodes of epiphora from the left eye. The discharge then increased, and a luxated lens was noted during an examination by a veterinary ophthalmologist as part of the preshipment examination. Initially, the lens was located in the anterior compartment but was in the vitreal compartment at the time of surgery, complicating the intracapsular extraction. After successful removal of the lens, the horse was transferred to a new institution without incident, where it appears to have adapted well to its probable loss of vision in the left eye. No further episodes of uveitis, corneal edema, or epiphora have been reported, and the horse has successfully foaled at the new institution.

Idiopathic sclerosing inflammation of the upper eyelid

Idiopathic sclerosing inflammation has commonly been found in the diffuse orbital tissues. We report the inflammation of the right upper eyelid in a 65-year-old man. Computed tomography and magnetic resonance imaging showed a diffuse mass localized only in the right upper eyelid. Histologic study of the excised specimen revealed dense collagenous tissue with sparse infiltration of mixed inflammatory cells. Immunohistochemical study showed that the inflammatory cells were largely composed of T cells (UCHL-1), histiocytes (PG-M1) and scattered plasma cells (immunoglobulins). No L26-positive B cells were found. We believe that idiopathic sclerosing inflammation of the upper eyelid, as demonstrated in our patient, may be rare.

[Melkersson-Rosenthal syndrome: anatomo-clinical and evolutive concepts]

PURPOSE

To inform ophthalmologists about the Melkersson-Rosenthal Syndrome. A new clinical classification is suggested.

METHODS

Commented observation and review of the litterature.

RESULTS

The presented case is characterized by an exclusive involvement of orbital sphere, due to inflammation of palpebral and orbital fat.

CONCLUSION

Melkersson-Rosenthal Syndrome can be divided into type 1 characterized by perioral lesions and type 2 characterized by periocular lesions, with preferential involvement of fat and evolution towards fibrosis.

Blepharoplasty

Cosmetic blepharoplasty is performed in various subspecialties, therefore articles appear in the ophthalmic, plastic surgical, otolaryngologic, and dermatologic literature. We review the past year's articles regarding evaluation, technique, adjunctive procedures, and complications. As the various techniques of upper-eyelid and lower-eyelid blepharoplasty have taken their place in the armamentarium of the aesthetic surgeon, attention has turned toward adjunctive procedures to enhance the surgical result.

Necrotising fasciitis of the orbit

A rare case of necrotising fasciitis affecting the face is described which, following prompt treatment and reconstruction, resulted in a successful outcome.

Dermis-fat graft for orbital reconstruction after subtotal exenteration

A surgical technique for reconstruction after subtotal orbital exenteration uses an autogenous dermis-fat graft. A musculocutaneous flap is advanced over the graft to provide the anterior vascular supply for the free dermis-fat graft. The periorbita and remaining orbital tissue provide the vascular supply posteriorly. This technique eliminates extensive skin grafting and delayed spontaneous healing. Wound healing is rapid and surgical morbidity is minimized. We have used this procedure in three patients with sebaceous gland adenocarcinoma, two patients with severe posttraumatic contracted sockets, and as a palliative procedure in one patient with a fungating choroidal melanoma and widespread metastasis.

Streptococcal gangrene of the eyelids. Case reports

Following a brief review of the literature, three patients with fulminating periocular infections resulting in necrosis of the eyelids are reported on. The case histories demonstrate certain common features, different aetiological factors and diverse end results. The pathogenesis, microbiology and treatment are discussed.

Blepharoplasty. Indications and preoperative assessment

Before performing a blepharoplasty, the surgeon must completely evaluate the patient to ascertain the proper diagnosis and indication for surgery and to identify any potentially complicating factors. The anatomy and physiology of the eyelids and lacrimal system must be understood in detail. A complete ophthalmologic examination should be performed to document preoperative decreased visual acuity or limited visual fields. The prevention of complications and the satisfaction of the patient are the goals of the blepharoplasty procedure. These require accurate assessment, proper preoperative diagnosis, and meticulous surgical technique.

Surgical management of floppy eyelid syndrome

Four patients (five eyes) with the classic findings of floppy eyelid syndrome all had chronic irritative symptoms, with papillary conjunctivitis, and a soft, rubbery, floppy, and easily everted upper eyelid. All affected eyes were treated surgically by a full-thickness eyelid shortening procedure which produced immediate relief of symptoms. Histopathologic study of the resected eyelids showed only an inflammatory infiltrate in the conjunctiva, but failed to identify specific cause for the lax tarsus.

Histopathology of meibomian gland dysfunction

We conducted a histopathologic study of he meibomian glands of seven patients (all men, ranging in age from 58 to 83 years) who had severe or moderately severe meibomian dysfunction and who were undergoing ectropion or entropion repair. Abnormal features included signs of obstruction and dilatation of ducts, enlargement of acini with cystic degeneration and squamous metaplasia, foreign-body reaction and granuloma formation, a mild increase in inflammatory cells, and abnormal keratinization. Demodex organisms were found in both acini and ducts of one patient. These findings were similar to those reported in other entities involving meibomian duct obstruction, probably related to abnormalities of keratinization, plays an important role in the pathogenesis of meibomian gland dysfunction.