Clinico-radiological findings of neuroendocrine tumour metastases to the orbit

Purpose: We present the clinico-radiological findings of neuroendocrine tumour metastases to the orbit.Methods: This was a multicentre, retrospective study of patients with neuroendocrine tumour metastases to the orbit. Data was collected from medical records across five different sites within Australia and the United Kingdom.Results: Nine patients (eleven lesions) were identified. The most common presenting complaint was diplopia (5/9, 56%). Disease occurred bilaterally in two patients. Seven patients (78%) had extraocular muscle involvement. The lateral recti (4/9, 44%) and superior recti (2/9, 22%) were the most commonly affected. Ocular presentation preceded primary tumour diagnosis in three patients (33%). On orbital imaging, metastases were most commonly reported as well circumscribed, ovoid or round, heterogeneous, contrast-enhancing masses. Features of intralesional haemorrhage and bony invasion are uncommonly reported.Conclusions: Neuroendocrine tumour metastasis to the orbit is uncommon. Metastases have a propensity for the extraocular muscles, commonly presenting as heterogeneous, well circumscribed, contrast-enhancing lesions on neuroimaging. New ocular symptoms, a history of neuroendocrine tumours, and these radiological findings, should lead to high clinical suspicion of metastatic disease. Atypical findings warrant biopsy to exclude other causes of orbital lesions.

The 2017 Doyne Lecture: the orbit as a window to systemic disease

A very large number of disorders affect the orbit, and many of these occur in the setting of systemic disease. This lecture covers selected aspects of orbital diseases with systemic associations in which the author has a particular clinical or research interest. Spontaneous orbital haemorrhage often occurs in the presence of bleeding diatheses. Thrombosis of orbital veins and ischaemic necrosis of orbital and ocular adnexal tissues occur with thrombophilic disorders, vasculitis, and certain bacterial and fungal infections. Non-infectious orbital inflammation commonly occurs with specific inflammatory diseases, including Graves' disease, IgG4-related disease, sarcoidosis, Sjögren's syndrome and granulomatosis with polyangiitis, all of which have systemic manifestations. IgG4-related ophthalmic disease is commoner than all these except Graves' orbitopathy. Some of these orbital inflammatory diseases are associated with an increased risk of B-cell lymphoma, usually marginal zone lymphoma of MALT type. Ocular adnexal lymphoma also has an association with infectious agents including Helicobacter pylori and Chlamydia psittaci. Orbital metastasis may be the first presentation of systemic malignancy. A number of orbital neoplasms occur in the setting of familial cancer syndromes, including Neurofibromatosis types 1 and 2. Study of the genetics and molecular biology of orbital diseases such as Graves' orbitopathy and idiopathic orbital inflammatory disease will yield useful information on their diagnosis and management.

Adult xanthogranulomatous disease of the orbit and ocular adnexa: new immunohistochemical findings and clinical review

BACKGROUND/AIMS

Adult xanthogranulomatous disease involving the ocular tissues is rare and poorly understood. Adult onset xanthogranuloma (AOX), adult onset asthma and periocular xanthogranuloma (AAPOX), necrobiotic xanthogranuloma (NBX), and Erdheim-Chester disease (ECD) are the four syndromes within this disorder, which is diagnosed by characteristic histopathology. Experience with eight cases prompted a multi-institutional effort to study the histopathology, immunohistochemistry, clinical findings, and systemic associations in this disorder.

METHODS

22 cases, including histopathological slides, were compiled. Published reports were identified by an English language Medline search (1966-2005) and review of reference citations. Each case in this series and the literature was classified as one of four syndromes and then analysed for age onset, sex, skin xanthoma, orbital location, immune dysfunction, internal organ and bone lesions, treatment, and outcome. The histopathology in each of these cases was reviewed by two pathologists. Immunhistochemical stains (CD3, CD4, CD8, L26) were performed in 14 cases where unstained slides were available.

RESULTS

137 cases were compiled. There was no sex or age difference between syndromes. AOX, AAPOX, NBX affect the anterior orbit, ECD tends to be diffuse and intraconal. Skin lesions are found in all the syndromes. Immune dysfunction was noted in all cases of AAPOX and NBX; 11% of NBX and all ECD patients had internal organ disease. Treatment included surgery, corticosteroids, other chemotherapeutic agents, radiotherapy, and combinations of these. No AOX or AAPOX deaths occurred; 66% of ECD patients died. All 22 cases had xanthoma cells; most had Touton giant cells. Lymphocytes were present in all cases and occurred as aggregates (mostly in AAPOX) or diffuse populations mixed with fibroblasts (mostly in ECD). Immunohistochemistry revealed the majority of these to be CD8+. Necrosis was most marked in NBX.

CONCLUSION

Adult xanthogranuloma of the orbit is rare, making prospective evaluation or meta-analysis impossible. The best treatment is unknown but seems to be with multiagent chemotherapy guided by histopathological, immunohistochemical, and systemic findings.

Scarring in external dacryocystorhinostomy: fact or fiction?

PURPOSE

To determine patients' long-term satisfaction with external dacryocystorhinostomy (DCR) with respect to the visibility of the scar and the resolution of symptoms.

METHOD

A single postal questionnaire with stamped addressed envelope for reply was sent to 204 sequential external primary DCR patients operated on by AAM from January 1999 to April 2002.

RESULTS

Of the 79% who replied, 67% rated the scar as invisible with 97% happy with the scar. In 92% the epiphora was either improved or cured and 85% would recommend the operation. Younger patients were significantly more likely to rate the scar as visible but equally likely to rate the scar as good or better. Women were no more likely than men to rate the scar as visible, but if visible, were more likely to consider the scar poor.

CONCLUSIONS

There was an excellent response rate for a single questionnaire. Patient satisfaction with the DCR scar is very high, with the majority considering the scar invisible. Only 3% remained unhappy with the scar. Overall patient satisfaction with external DCR is very high, for the majority of patients the procedure is effective, and 85% would recommend the operation.

Orbital decompression in Graves’ orbitopathy: efficacy and safety

BACKGROUND

Vision-threatening compressive optic neuropathy occurs in a minority of patients with Graves' orbitopathy. Surgical orbital decompression, systemic glucocorticoids and orbital irradiation are treatment options. Orbital decompression is being performed on an increasing number of patients for other indications such as corneal exposure and disfiguring proptosis.

AIMS

To examine the outcomes of surgical orbital decompression for Graves' orbitopathy by one surgeon.

METHODS

An analysis of a retrospective case series of 88 consecutive patients (151 orbits) who underwent orbital decompression for Graves' orbitopathy between April 1991 and November 2002.

RESULTS

The indication for surgery was compressive optic neuropathy for 57 orbits; 94 orbits had an indication other than optic neuropathy. Of those with optic neuropathy, 94% had improvement or maintenance of visual acuity and 93% had improvement in colour vision after decompression. The overall mean reduction in proptosis was 4.7 mm. Of all patients, 30% had new or worsened diplopia postdecompression. Patients with optic neuropathy were more likely to develop new or worsened diplopia than those without optic neuropathy.

CONCLUSIONS

Orbital decompression is a safe procedure and effective in improving vision in compressive optic neuropathy. It is effective in reducing proptosis, therefore improving exposure keratopathy and cosmesis. However, new or worsened diplopia is a significant postoperative complication, and subsequent strabismus surgery might be required. This is an important consideration, especially for patients undergoing surgery for non-optic neuropathy indications.

Orbitofrontal cholesterol granuloma

Cholesterol granuloma of the orbital bones is a rare but readily recognisable condition. It is an osteolytic lesion with a granulomatous reaction surrounding cholesterol crystals, old haemorrhage and a fibrous capsule. There is a male preponderance and it usually occurs in young or middle-aged men. It is treatable with drainage and curettage via an orbitotomy, and craniotomy or wide bone removal is almost never required. Six cases of this condition were reviewed to highlight the typical clinical presentation, computed tomography and magnetic resonance results, and surgical management.

A brief history of punctoplasty: the 3-snip revisited

PURPOSE

To determine when and how to perform punctoplasty, review the history, and determine the efficacy of posterior ampullectomy.

METHOD

Retrospective analysis of 53 cases of punctal stenosis, operated by a single surgeon by means of posterior ampullectomy via 3-snips. A review of the history of the procedure from papers found with a Medline search for 1-snip, 2-snip, 3-snip, and punctoplasty.

RESULTS

In all, 102 sets of notes were reviewed. The age range was from 9 to 89 years with a mean age of 56 years. A total of 74% of patients were female. We excluded 22 patients who had additional surgery and 16 patients who elected not to have surgery. There was no comment as to success or failure in four sets of notes and seven notes could not be found; these cases were also excluded. Of the remaining 53 patients, success was documented in 49 cases, or 92%.

CONCLUSIONS

The historical review helps explain the debate about the procedure. The retrospective review confirms that posterior ampullectomy via 3-snips is an effective procedure.

Upper lid loading with gold weights in paralytic lagophthalmos: a modified technique to maximize the long-term functional and cosmetic success

PURPOSE

To describe a modified fixation technique to improve the long-term functional and cosmetic success of upper lid loading with gold weights.

METHOD

A retrospective single surgeon study of combined upper pre-tarsal and direct levator fixation of the gold weight. The minimum follow-up period was 12 months.

RESULTS

Gold weights were implanted with the modified technique into 29 patients. The gold weight was removed in two cases due to infection and in one case due to ptosis. There was no loss of function over the follow-up period and the cosmetic outcome was good or very good in all cases. The follow-up ranged from 12 to 84 months with a mean of 40 months.

CONCLUSIONS

Combined upper pre-tarsal fixation and direct levator fixation is effective in maximizing both the long-term functional and cosmetic success of upper lid loading with gold weights in paralytic lagophthalmos.

A technique for reconstruction of upper lid marginal defects

BACKGROUND/AIMS

Reconstruction of large full thickness upper lid defects that cannot be closed directly often rely on utilising the lower lid. An example is the Cutler Beard procedure. A one stage technique for repair of large horizontal upper lid defects utilising local posterior and anterior lamella advancement flaps is described and the results reported.

METHOD

Eight cases with upper lid defects repaired utilising this technique were reviewed retrospectively. The procedures were carried out by one surgeon. The upper lid lesions were removed under frozen section control. The mean follow up time was 35 months.

RESULTS

All patients had a good cosmetic result. One patient had a recurrence of the upper lid lesion. Two patients complained of corneal irritation from lanugo hairs. The technique was modified to prevent this complication.

CONCLUSIONS

Large upper lid marginal defects can be readily repaired using the technique described with local advancement flaps with no significant complications.

Australasian orbital and adnexal Wegener's granulomatosis

OBJECTIVE

To report a retrospective case series of 29 Australian and New Zealand patients with orbital and adnexal Wegener's granulomatosis (WG).

DESIGN

Retrospective case series.

PARTICIPANTS

Twenty-nine cases of orbital and adnexal WG were identified.

METHODS

A number of oculoplastic surgeons and other clinicians in Australia and New Zealand was asked about their experience with orbital and adnexal WG. Clinical data regarding these cases were conveyed by means of a questionnaire. Cases of ophthalmic WG without features of orbital or adnexal disease were excluded.

MAIN OUTCOME MEASURES

Data obtained from the questionnaire includes age, gender, limited or generalized disease, antineutrophil cytoplasmic antibody (ANCA) status, symptoms and signs: nasolacrimal obstruction, sinusitis, fistula/orbital bone erosion, orbital mass/proptosis, extraocular muscle/diplopia, visual acuity reduction caused by optic nerve compression, orbital pain, lid edema/erythema, biopsy status, and treatment status.

RESULTS

Twenty-nine patients with orbital and adnexal WG were identified and described. Symptoms included awareness of an orbital mass, epiphora, orbital pain and diplopia. Signs included an orbital mass or proptosis (69%), nasolacrimal duct obstruction (52%), limited ocular rotations (52%), lid erythema and edema (31%), bony destruction (21%), and reduced visual acuity (17%). Two patients had a persistent nasolacrimocanthal fistula. Cytoplasmic pattern antineutrophil cytoplasmic antibodies (c-ANCA) were present in 52% of patients, and in 9 of 10 patients with generalized disease. However, c-ANCA was positive in only 32% (6 of 19) of patients with limited WG. Perinuclear pattern antineutrophil cytoplasmic antibodies (p-ANCA) was positive in 10% of cases.

CONCLUSIONS

To diagnose and treat ophthalmic WG effectively, the clinician must be aware of its protean orbital and adnexal manifestations. WG may occur with or without systemic involvement, and c-ANCA was negative in approximately half our cases. Our cases also demonstrated two orbital fistulae, an observation previously believed to be rare.

A prospective randomized study comparing division of the pedicle of modified hughes flaps at two or four weeks

PURPOSE

To compare the incidence of upper and lower eyelid malposition or other complications when the pedicle in modified Hughes flap repair of the lower eyelid is divided at 2 versus 4 weeks.

METHODS

A prospective randomized study. Data were collected on patient age and sex, horizontal tumor dimension, upper and lower eyelid position before surgery and 3 months after division of the pedicle, and any complications.

RESULTS

Complete data from 60 patients were collected, with 32 patients in the 2-week group and 28 patients in the 4-week group. The two groups were not significantly different in terms of sex, age, or tumor dimensions. In the 2-week group, the upper eyelid was within 1 mm of its preoperative position at 3 months in 25 of 32 patients (78.1%) and in 26 of 28 (92.8%) in the 4-week group. The lower eyelid was within 1 mm of its normal position in 27 of 32 patients in the 2-week group (84.4%) versus 25 of 28 (89.3%) in the 4-week group. Statistical analysis showed no significant difference between the 2- and 4-week groups for upper and lower eyelid position at 3 months. Other complications were uncommon and evenly spread between the two groups.

CONCLUSIONS

A modified Hughes flap pedicle may be divided at 2 weeks with no increased incidence in upper or lower eyelid malposition or other complication.

Orbital and optic nerve trauma

The ability to measure orbital volume expansion and correlate this with later enophthalmos has advanced radiological assessment of patients with orbital floor fractures. Attempts have also been made to classify orbital floor fractures on the basis of their configuration on CT scan and to correlate this with outcome in terms of ocular motility. A small subset of relatively undisplaced floor fractures with tight entrapment of tissues occurring most commonly in young patients has been identified, and early surgical intervention has been recommended for these. The range of alloplastic materials available for orbital rim and wall fractures has increased, and complications related to various alloplastic implants continue to be reported. Optic nerve trauma has received considerable attention but remains a difficult management area. Recent literature on this subject shows no definite benefit for optic nerve decompression or high dose corticosteroids, although no prospective randomized study has been possible.

Fulminant orbital cellulitis with complete loss of vision

Bacterial orbital cellulitis is a condition that rarely presents with complete loss of vision. A case is reported of a 69-year-old man who presented with fulminant onset of proptosis, significant ophthalmoplegia and no perception of light. Computed tomography showed no evidence of paranasal sinus disease. Despite treatment with intravenous flucloxacillin, ceftriaxone and metronidazole, and later, penicillin after Streptococcus pyogenes was grown from tissue culture, there was no improvement in vision; however ocular motility returned to normal.

Nontraumatic subperiosteal orbital hemorrhage

PURPOSE

Nontraumatic subperiosteal orbital hemorrhage (NTSOH) has been reported rarely in association with sudden elevation of cranial venous pressure, generalized diseases with bleeding diatheses, and paranasal sinusitis. To define more clearly the clinical and imaging characteristics of NTSOH, we evaluated nine cases seen by the authors and reviewed previous case reports.

DESIGN

Retrospective, noncomparative case series.

PARTICIPANTS

Nine patients (10 eyes) with NTSOH.

INTERVENTION

All patients underwent computed tomography scans of the orbits. Patients with typical clinical and imaging features and normal visual function were observed. Those with an uncertain diagnosis or visual compromise underwent surgical drainage of the hematoma.

MAIN OUTCOME MEASURES

Resolution of proptosis, diplopia, lid swelling, and ptosis.

RESULTS

Nine patients ranging from birth to 73 years of age were identified. All were females. The lesions were located superiorly in eight patients (one patient had bilateral lesions) and medially in one patient. Most were associated with sudden elevation in venous pressure (vomiting, strangulation, straining), and most required no surgical intervention. The bilateral case occurred in the setting of disseminated intravascular coagulation and was the only case associated with visual loss possibly resulting from ischemic optic neuropathy.

CONCLUSIONS

Nontraumatic subperiosteal orbital hemorrhage may occur at any age, usually secondary to sudden elevation in venous pressure. It is nearly always superior. The clinical and radiologic features are sufficiently characteristic to allow conservative treatment in the absence of visual compromise.

Sino-orbital fistula: two case reports

A fistula between the paranasal sinuses and the orbit as a late complication of orbital fractures is rare and may present with intermittent symptoms due to air passing into the orbit. A case note review of two patients with sino-orbital fistula is presented. Two patients, 23- and 30-year-old males, presented with intermittent symptoms of globe displacement, diplopia or discomfort months after repair of an orbital floor fracture with a synthetic orbital floor implant. The symptoms occurred after nose blowing. They were both cured by removal of the implant and partial removal of the tissue surrounding the implant. A sino-orbital fistula may complicate the otherwise routine repair of an orbital floor fracture, but may be cured by removal of the implant and part of the surrounding pseudocapsule.

Reversal of floppy eyelid syndrome with treatment of obstructive sleep apnoea

PURPOSE

To describe the beneficial effects of treatment of obstructive sleep apnoea on the symptoms and signs of floppy eyelid syndrome.

METHOD

A case of sleep apnoea with associated floppy eyelid syndrome is reported.

RESULTS

A 32-year-old man presented with left floppy eyelid syndrome and a known diagnosis of obstructive sleep apnoea. He underwent treatment for 4 years with continuous positive airways pressure by mask during sleep and the symptoms and signs of his floppy eyelid syndrome disappeared.

CONCLUSION

Treatment of obstructive sleep apnoea may reverse the changes of floppy eyelid syndrome.

Secondary haemorrhage after dacryocystorhinostomy

OBJECTIVE

To describe the incidence, clinical features, possible risk factors and outcome of patients suffering secondary haemorrhage after dacryocystorhinostomy (DCR).

METHODS

Records of all patients undergoing external DCR by one surgeon (AAM) over a 6-year period were analysed retrospectively.

RESULTS

After 293 DCR operations in 260 patients, 10 patients had a secondary haemorrhage (one after bilateral DCR), usually between days 4 and 10 post-operatively (mean 6.8 days). Six of the 10 were hospitalized for 2-5 days (mean 2.8 days), all of whom had nasal packing, intravenous antibiotics and intravenous fluids; none required blood transfusion. Three patients had immune system defects, three had used non-steroidal anti-inflammatory drugs (NSAID) and four had no obvious risk factors. All 10 had a successful outcome following DCR (compared to an overall failure rate of 25/293 (8.5%): 16 anatomical and nine functional).

CONCLUSIONS

Secondary haemorrhage after DCR was found to occur after 3.8% of DCR. Risk factors include being immunocompromised and taking NSAID prior to surgery. The haemorrhage did not adversely affect surgical outcome.

Current treatment and outcome in orbital cellulitis

BACKGROUND

Bacterial orbital cellulitis is an uncommon condition previously associated with severe complications. The purpose of this paper is to describe current investigations and treatment in orbital cellulitis, establish their effectiveness and to describe the incidence of complications and surgical intervention.

METHODS

A chart review of all patients admitted to the Royal Victorian Eye and Ear Hospital and the Royal Children's Hospital, Melbourne with a diagnosis of orbital cellulitis for the period July 1993 to July 1997.

RESULTS

A total of 52 patients fulfilling the diagnostic criteria for orbital cellulitis were identified. Paranasal sinus disease was the commonest predisposing cause, especially in the paediatric age group. Diagnosis was made clinically with radiological confirmation in all cases. Microbiological investigation and results varied. The commonest species isolated were Staphylococci and Streptococci. Three cases of mixed anaerobes and one of Clostridium were seen. Cultures from abscess cavities and infected sinuses gave the highest positive yield (50-100%). Blood cultures were taken in 26% of adults and in 56% of children; none was positive. Treatment was either by intravenous broad-spectrum antibiotics alone or with surgery to drain orbital abscesses, usually n conjunction with sinus surgery. No patient suffered permanent visual impairment other than one case of enucleation for endophthalmitis that had caused orbital cellulitis. There was one case of permanent ocular motility impairment, and one of meningitis.

CONCLUSIONS

Despite its past history of severe morbidity and even mortality, adequately treated orbital cellulitis rarely has significant morbidity today. Paranasal sinus disease remains the commonest cause. Culture of infected paranasal sinuses or pus from abscesses is most likely to yield significantly positive results in this study. Blood cultures were not helpful.

Lacrimal gland abscess: two case reports

BACKGROUND

Bacterial dacryoadenitis is rare and suppuration leading to abscess formation within the lacrimal gland has been very rarely reported in the antibiotic era.

METHODS

The medical records and investigation results, including computed tomography (CT), of two patients with lacrimal gland abscess were reviewed.

RESULTS

Two cases of lacrimal gland abscess, one a 28-year-old male and the other a 64-year-old female, are described. Both demonstrated a characteristic low-density area within an enlarged lacrimal gland on CT. The first case had been treated with antibiotics and the abscess, when drained, was sterile. The second case settled spontaneously. Neither patient suffered any sequelae of dry eye.

CONCLUSIONS

Although rare, lacrimal gland abscess may still occur and may require surgical drainage if spontaneous resolution does not occur.

Subconjunctival fat prolapse

PURPOSE

Subconjunctival orbital fat prolapse has been rarely described in the literature and is frequently confused with other conjunctival tumours, such as dermolipoma. The purpose of the present study was to describe the clinical features and treatment of a series of patients with subconjunctival orbital fat prolapse.

METHODS

Review of clinical records.

RESULTS

Twelve patients with subconjunctival orbital fat prolapse were identified. Eight had a superotemporal prolapse and five of these were bilateral. All but one were male and most were elderly and tended to be obese. Five of these patients underwent surgical excision of the prolapsed fat for symptoms of discomfort or for cosmesis. Four atypical unilateral cases were seen in younger patients with fat prolapse occurring superonasally in three and inferiorly in one. In one case there was a history of trauma

CONCLUSIONS

Subconjunctival orbital fat prolapse typically occurs superotemporally in obese elderly males and is easily differentiated from other lesions, such as dermolipoma. The prolapsed orbital fat may be excised via the conjunctiva.

Late infection of hydroxyapatite orbital implants

BACKGROUND

Exposure and minor complications of hydroxyapatite orbital implants are common. Infection appears to be rare and fibrovascular ingrowth into hydroxyapatite implants may make infection and extrusion less likely than with other types of orbital implant.

METHODS

We describe three cases of chronic low-grade infection of hydroxyapatite implants, occurring late after apparently uncomplicated surgery, with tiny or inapparent areas of conjunctival loss or exposure.

RESULTS

Two of the three cases grew Staphylococcus oureus on culture. All three implants ultimately needed to be removed. A characteristic histological pattern was seen, with abrupt transition between vascularized and abscessed implant.

CONCLUSIONS

Chronic infection of hydroxyapatite implants can occur late, in the absence of large conjunctival defects, or other obvious risk factors. While exposure of the implant to pathogens through a breach in the conjunctiva may have been a factor, it appeared that the infection may have arisen in an avascular portion of the implant prior to the conjunctival breakdown in one or more of these cases.

Persistent infra-orbital nerve hyperaesthesia after blunt orbital trauma

BACKGROUND

Hyperaesthesia involving the infra-orbital nerve is rarely associated with orbital floor fracture.

METHODS

An 11-year-old boy and a 34-year-old man had persistent and severe hyperaesthesia in the distribution of the infra-orbital nerve 12 and 26 months, respectively, after blunt orbital trauma.

RESULTS

Surgical decompression of the infra-orbital nerve resulted in rapid and complete resolution of the hyperaesthesia in both cases.

CONCLUSION

Persistent hyperaesthesia of the infra-orbital nerve is another indication for exploration of the orbital floor following blunt orbital trauma.

Lacrimal canalicular obstruction associated with topical ocular medication

PURPOSE

To describe the association between the use of various types of topical ocular medications and acquired lacrimal canalicular obstruction in 14 patients.

METHODS

The records of all patients in the author's practice with either lacrimal canalicular or punctal occlusion associated with the use of topical ocular medication were reviewed.

RESULTS

Fourteen cases were identified. The obstructions occurred at any point from the punctum to the common canaliculus, but most commonly occurred 2-5 mm from the lacrimal punctum. There was an association with various degrees of clinically apparent subconjunctival scarring maximal at the inner canthus, rarely to a severe degree, with symblepharon, medial canthal keratinization and cicatricial medial entropion. In some cases, no subconjunctival scarring could be clinically detected. Topical medications used were often multiple and included prednisolone acetate/phenylephrine hydrochloride (n = 5), timolol maleate (n = 5), pilocarpine (n = 3), dipivefrine hydrochloride or adrenaline (n = 3), chloramphenicol (n = 3), tobramycin (n = 3), indomethacin (n = 2), ecothiopate iodide (n = 1), betaxolol (n = 1), dexamethasone (n = 1), tropicamide (n = 1) and the long-term use of naphazoline and various artificial tear preparations (n = 1). The duration of exposure ranged from 3 weeks to 20 years, with seven patients having used drops for 3-6 weeks. Seven patients had surgical repair, three by dacryocystorhinostomy (DCR) and glass by-pass tube (all successful), three by canalicular repairs (one failed) and one by DCR and canalicular repair that restenosed at the puncta, who then had successful punctoplasty and silicone intubation.

CONCLUSIONS

Lacrimal canalicular obstruction may occur after relatively short-term exposure to topical ocular medications or as part of a more widespread cicatricial reaction in patients on long-term medication. While a direct causal relationship cannot be confirmed, there appears to be a strong association and the site of the obstructions makes other causes unlikely.

Inferior rectus rupture following blowout fracture

BACKGROUND

Extra-ocular muscle rupture is uncommon, usually seen after penetrating trauma or surgery. It is a very rare cause of diplopia following blunt orbital trauma.

METHODS

A patient who presented with no inferior rectus function after blunt orbital trauma is described.

RESULTS

Computed tomography (CT) scans demonstrated a large orbital floor fracture and suggested that the inferior rectus muscle was ruptured. This was confirmed at operation. Despite anatomical repair, there was no postoperative improvement in ocular motility.

CONCLUSIONS

Traumatic rupture of the inferior rectus is rare. Forced duction and force generation testing and CT are important in diagnosing ocular motility defects following orbital trauma.

Orbital osteoma in Gardner's syndrome

PURPOSE

To report the association of an orbital osteoma with Gardner's syndrome (familial polyposis coli leading to carcinoma, multiple osteomas and skin and soft tissue tumours).

METHOD

A review of patient records.

RESULTS

A 29-year-old male with known Gardner's syndrome presented with long-standing right proptosis due to an osteoma of the medial wall and roof of the orbit. He had previously had prophylactic colectomy and one other osteoma of the skull excised.

CONCLUSION

Although orbital osteoma in the setting of Gardner's syndrome is rare, it should be recognized as an association because of the importance of the intestinal polyposis, which leads to carcinoma if untreated.

Perineural spread of cutaneous squamous cell carcinoma via the orbit. Clinical features and outcome in 21 cases

OBJECTIVE

To describe the clinical features, treatment, and outcome of a series of patients with perineural spread (PNS) of cutaneous squamous cell carcinoma (SCC) via the orbit.

DESIGN

A cohort study.

PARTICIPANTS

Twenty-one patients identified with PNS of cutaneous SCC via the orbit.

INTERVENTION

Patients were treated with various combinations of conservative or radical surgery, external beam radiation therapy, and chemotherapy.

RESULTS

Of 21 cases, 17 (81%) were male. Age at presentation with PNS ranged from 38 to 82 years (median, 66 years). The forehead and eyebrow were the most common site of the primary lesion. All but one had altered or decreased sensation, but only nine presented with pain. Fourteen (67%) had ophthalmoplegia at presentation, and 14 (67%) had evidence of PNS involving branches of the facial nerve. Despite combinations of radical surgery, conservative surgery, and radiation therapy, no method of treatment appeared more effective, and 14 patients died from 9 months to 5 years after presentation with PNS (median, 3 years), usually from local and intracranial disease. Two survived to 14 and 18 years, one is alive at 3 years with recurrent local and distant disease, and four are alive without evidence of disease at 2, 3, 4 and 12 months after radiation therapy.

CONCLUSIONS

Perineural spread of cutaneous SCC via the orbit carries a poor prognosis. Early radiation therapy may offer the best form of palliation. The role of radical surgery probably is limited once orbital involvement is apparent, as the cavernous sinus and facial nerve branches usually are involved.

Iron overload is a risk factor for zygomycosis

Well-recognized risk factors for zygomycosis include diabetic ketoacidosis, immunocompromise, and deferoxamine therapy for iron or aluminum overload, usually in patients undergoing kidney dialysis. We report a case of fatal nasal-orbital-cerebral zygomycosis in an 82-year-old man with known myelodysplasia and well-controlled diabetes. He was not receiving deferoxamine. Despite radical surgery and amphotericin B therapy, he died; primary hemochromatosis with gross iron overload was found post mortem. Experimental evidence suggests iron overload without deferoxamine therapy may be a risk factor for zygomycosis; the findings in this case would support this hypothesis.

Floppy eyelid syndrome and obstructive sleep apnea

Floppy eyelid syndrome (FES) usually affects middle-aged obese men, presenting as a unilateral or bilateral chronic papillary conjunctivitis. The upper eyelid is lax, floppy, and easily everted. The laterality corresponds to the side the patient sleeps on. An association with obstructive sleep apnea (OSA) has been suggested. A personal series of 17 new cases is presented, and 79 previously reported cases are reviewed to give a detailed description of the syndrome. In addition to the classical presentation, patients may present with upper lid ptosis, lash ptosis or trichiasis, lower lid ectropion or rarely entropion, or corneal complications. Eight patients with FES were investigated for OSA. Twenty other patients with known OSA were examined for FES and other possibly associated ocular features. All eight patients referred for sleep studies were found to have OSA. One of the 20 patients with known OSA was found to have FES, and two had features of early asymptomatic FES. One patient with FES and OSA had normal tension glaucoma. Patients with FES should be considered for sleep studies because of the known morbidity of OSA. Simple screening of patients with OSA may detect FES and avoid late corneal complications that can compromise vision.

Malignant melanoma of the lacrimal sac complicating primary acquired melanosis of the conjunctiva

An 81-year-old woman with primary acquired melanosis of the conjunctiva had multinodular invasive malignant melanoma, with one nodule engulfing the superior lacrimal punctum. At exenteration, the lacrimal sac was noted to be involved with melanoma, and an en bloc resection of the orbital contents along with the medial orbital wall and the medial wall of the maxillary antrum was performed to excise the lacrimal drainage apparatus. In situ melanoma was found in the superior canaliculus with invasive melanoma in the lacrimal sac. In situ melanoma was also found in the ductules of the lacrimal gland and the accessory lacrimal glands of the fornix. The patient died 8 months later of metastatic melanoma. The involvement of the lacrimal drainage apparatus by primary acquired melanosis or in situ melanoma makes clinical monitoring and management difficult.

Atypical choristomatous cysts of the orbit

BACKGROUND

The commonset choristomatous cysts of the orbit are dermoid and epidermoid cysts, which are lined by kerantinizing squamous epithelium. They typically occur in the superior orbit, most commonly superotemporally. Other types, lined by different epithelia, and other orbital sites are much less common.

METHODS

Five cases of atypical orbita cystic choristomas that presented over the past 6 years are reported. The clinical and radiological features, surgical approach and findings, and histology, are described. Similar cases from the literature are reviewed and possible aetiology discussed.

RESULTS

Four of the cysts were lined by a non-keratinizing epithelium resembling conjunctiva; two had adnexal structures in their walls. Compared with typical dermoid and epidermoid cysts, these 'conjunctival dermoids' and 'conjunctival cysts' of the orbit tended to present later in life, none were associated with bony defects, and three of the four occurred in the superomedial quadrant. One case occurred inferiorly, a rare site for orbital conjunctival dermoids and cysts, or typical dermoids and epidermoids. The fifth case, also inferior, is an example of a cyst within choristomatous lacrimal tissue.

CONCLUSION

Choristomatous cysts of the orbit may occur with non-keratinizing epithelial linings, and such cysts tend to differ clinically from the commoner dermoids and epidermoids. They may also occur in atypical sites such as the inferior orbit.

Embolization of carotid cavernous fistulas via the superior ophthalmic vein

BACKGROUND

Carotid cavernous fistulae are treatable by various means, one of which is embolization via the superior ophthalmic vein (SOV). The use of this technique over the past 12 years at the Royal Melbourne Hospital, Victoria, Australia, is reviewed.

METHODS

Five patients with carotid cavernous fistulas were treated with embolization of the fistula via the surgically isolated SOV.

RESULTS

Each patient had successful endovascular closure of the fistula using embolization via the SOV approach.

CONCLUSIONS

Treatment of certain types of carotid cavernous fistulas that cannot be closed by the conventional endovascular (arterial and venous) approaches can be successfully closed by using a transvenous approach through the SOV.

Orbital decompression for thyroid orbitopathy

BACKGROUND

Severe thyroid orbitopathy may result in optic neuropathy, corneal exposure and disfiguring proptosis. Orbital decompression has most commonly been performed for optic neuropathy, but with improved techniques, more patients are undergoing decompression for other indications.

PURPOSE

This report evaluates the results and morbidity of orbital decompression for thyroid orbitopathy performed by one surgeon.

METHODS

The records of 33 patients (53 orbits) undergoing orbital decompression for thyroid orbitopathy were analysed for changes in visual acuity and colour vision (where the indication was optic neuropathy) and reduction in proptosis. Complications were also analysed.

RESULTS

Visual acuity and colour vision improved in all 33 eyes with optic neuropathy in the short term postoperative period (4 weeks), but later deteriorated in five eyes (6.6%) of 4 patients (19%). Proptosis decreased by a mean 5.3 mm (range, 1-10). Diplopia developed or worsened overall in 10 of 33 patients (30%), but only in one of 12 (8%) where the indication was cosmesis or corneal exposure. Diplopia improved in 2 of 33 (6%). All patients with symptomatic diplopia achieved binocular single vision in a useful range after one and sometimes two squint procedures. No patient lost vision as a result of surgery.

CONCLUSIONS

Orbital decompression is effective in improving vision in most patients with thyroid optic neuropathy, but induces or worsens diplopia in a high proportion of these patients. Proptosis can be effectively and dramatically improved.

Merkel cell tumour occurring simultaneously in the upper and lower eyelids

PURPOSE

To highlight an unusual presentation of two Merkel cell tumours in the same patient.

RESULT

We report a case of two Merkel cell tumours occurring simultaneously in the upper and lower eyelids of an elderly woman, a unique occurrence. Wide local resection and reconstruction resulted in microscopic clearance of the tumours. Lymphatic spread was detected, a common feature. She had previously undergone excision of a similar lesion from the lower eyelid.

CONCLUSION

Merkel cell tumour is a rare tumour of the elderly that often locally recurs and metastaseses early. Treatment consists of wide local excision with or without adjuvant radiotherapy. Juxtaposing lesions on the eyelids have not been previously reported. We postulate that this patient showed local recurrence and a new tumour of the upper eyelid simultaneously.

Early division of the conjunctival pedicle in modified Hughes repair of the lower eyelid

BACKGROUND AND OBJECTIVE

The modified Hughes repair of the lower eyelid (upper lid tarsoconjunctival flap and skin graft or flap) after resection of marginal lesions has an established place in oculoplastic surgery. Previous recommendations for the timing of the division of the conjunctival pedicle have varied greatly from 3 weeks to 6 months. This study was performed to determine the safety of division of the pedicle at 2 weeks.

PATIENTS AND METHODS

A series of 25 patients in whom the tarsoconjunctival pedicle in a modified Hughes repair of the lower eyelid was divided at 2 weeks were prospectively evaluated. All cases had a full-thickness skin graft placed as an anterior lamella of the reconstructed eyelid.

RESULTS

In all cases there was a healthy and viable lower lid with brisk bleeding from the newly created lid margin at the time of pedicle division. There were no instances of infarction of any portion of the reconstruction, shrinkage, or retraction of the lower lid.

CONCLUSION

Two weeks is a long enough time to wait prior to division of the conjunctival pedicle in the modified Hughes repair of the lower eyelid.

An alternative method of closed silicone intubation of the lacrimal system

An alternative method of closed lacrimal intubation is described, the basis of which is to place the end of a piece of silicone tubing over the end of a small-diameter metal introducer, stretch the silicone tubing back along the introducer, and then pass the introducer together with the tubing through the lacrimal system into the nasal cavity. The tubing is visualized in the inferior meatus, from where it is retrieved, and then the introducer is withdrawn. The other end of the tubing is passed in a similar fashion. The technique is easily mastered, inexpensive, and less traumatic than other described techniques.

Hemifacial atrophy: an unusual cause of upper eyelid retraction

Progressive hemifacial atrophy or Parry Romberg syndrome may present with variable ocular features, the commonest being enophthalmos. We report a mild case in a 62-year-old man who presented with upper eyelid retraction, nocturnal lagophthalmos, and symptoms of corneal exposure. Recession of the levator muscle corrected the lid retraction and abolished the symptoms of corneal exposure.

Spontaneous hemorrhage within the rectus muscle

PURPOSE

To describe, in three patients, the rare condition of spontaneous hemorrhage within the rectus muscle.

METHODS

The records of three patients with a diagnosis of spontaneous hemorrhage within a rectus muscle were reviewed.

RESULTS

Three adults had sudden unilateral painful proptosis with clinical and computed tomographic findings consistent with hemorrhage within a rectus muscle; in two patients, the presence of recent hemorrhage was confirmed on magnetic resonance imaging. In all three patients, the hemorrhage resolved spontaneously.

CONCLUSIONS

Spontaneous hemorrhage within a rectus muscle may occur in otherwise healthy adults without any apparent underlying cause. In the absence of visual deterioration, no treatment is required, and complete clinical resolution may be anticipated.

Granular cell tumours of the orbit

Granular cell tumours are uncommon benign tumours, occurring in various sites in the body, and very rarely in the orbit or ocular adnexa. Four cases of orbital granular cell tumour are described, with detailed light and electron microscopic description of one tumour arising in the orbital apex of a child. The histogenesis of granular cell tumour is uncertain, with many authors proposing an origin from Schwann cells. In central nervous system granular cell tumours, an astrocytic cell origin has been proposed. Evidence is presented for an origin from astrocytes in a child whose tumour arose in or adjacent to the optic nerve.

Symptomatic nocturnal lagophthalmos

Nocturnal lagophthalmos producing symptoms of corneal exposure is not uncommon. We diagnosed 40 patients with the condition over a six-month period. In 12 (30%), alcohol intoxication preceded the symptoms. Other factors included the use of hynotics, cosmetic blepharoplasty, botulinum toxin injection for blepharospasm, facial palsy, dysthyroid eye disease and cicatrising skin disease of the lids. In the largest group (17 patients, 42%), no cause could be found, but five of these had either first-degree relatives who slept with their eyes open, or had been observed with nocturnal lagophthalmos. In most patients, symptoms were unilateral. Testing of Bell's phenomenon did not predict eye position during sleep as manifested by distribution of punctate corneal staining. All patients were relieved of their symptoms by simple treatment modalities and none required surgery.

Lateral orbitotomy--a review

Lateral orbitotomy is the standard surgical approach to lesions in the middle third of the orbit, to many lesions in the posterior third of the orbit and to benign lacrimal gland tumours. The indications, surgical technique and complications are discussed.

Primary orbital liposarcoma: clinical and computed tomographic features

Liposarcoma of the orbit is rare. The clinical and radiological characteristics of two cases, of myxoid and pleomorphic types, are reported. In neither case was the histological diagnosis evident before surgery.