Orbital inflammatory disease in relapsing polychondritis

We present a 73-year-old Chinese male with bilateral relapsing, remitting orbital inflammatory disease associated with relapsing polychondritis. He first presented with right orbital inflammation that did not improve despite antibiotic treatment. Computer tomography (CT) of the orbits showed a soft tissue mass along the roof of the orbit, which was biopsied, revealing acute on chronic inflammation. There was complete resolution of his orbital inflammation within 2 weeks of initiating systemic steroid treatment. He subsequently developed recurrent bouts of left orbital inflammation. One year later, he was diagnosed with relapsing polychondritis and subsequently developed multiple myeloma seven years later. Comanagement with a rheumatologist will be helpful to achieve control of the disease with judicious use of immunosuppression. Long-term follow-up of the patient will be necessary to monitor for malignant transformation of the orbital lesion, as well as the development of other hematologic malignancies.

A survey of the histopathology of lacrimal gland lesions in a tertiary referral centre

PURPOSE

To describe the histopathological distribution of biopsied lacrimal gland lesions in a tertiary referral centre in Singapore.

METHODS

This was a retrospective chart review. Clinical records of patients who underwent lacrimal gland biopsy at a tertiary referral centre in Singapore between 2000 to 2010, were reviewed. Data collated included patient demographics, clinical presentation, association with systemic disease and histopathological diagnosis.

RESULTS

Sixty-nine patients were studied. Median age of presentation was 50 years. Forty patients (58%) were female and the majority (84%, n = 29) were Chinese. The mean follow-up duration was 35.0 ± 34.5 months. 30.4% (n = 21) of the patients had bilateral disease. Chronic dacryoadenitis (46%, n = 32) was the most common histopathological diagnosis, followed by lymphoproliferative disorders (38%, n = 26) and pleomorphic adenoma (10%, n = 7). The diagnoses in four other patients included adenoid cystic carcinoma, lacrimal gland hypertrophy, lacrimal duct cyst and orbital vascular malformation.

CONCLUSION

Chronic dacryoadenitis and lymphoproliferative disorders are the two commonest causes of lacrimal gland lesions in our series. Although many cases remain non-specific, about 60% have a specific inflammation that may be associated with a systemic disease. As one third of our patients with lymphoproliferative disease of the lacrimal gland had an associated systemic lymphoma, patients with such lesions should be referred for investigation of possible systemic lymphoma. The results of our study can aid in providing a more targeted approach to patient management.

Bilateral Kuttner tumours of the lacrimal glands

Kuttner Tumour is a chronic inflammatory disease diagnosed histologically. It is under-diagnosed due to lack of awareness of the disease. We present a case of a 40-year old female with recurrent upper lid swelling. Biopsy revealed the diagnosis of Kuttner Tumours of the lacrimal glands. Although surgical excision is a treatment option, it can be treated with a course of steroids. Our patient opted for conservative management. We describe the presentation and course of the case, with an emphasis on the histological features of the tumour.

A 5-year Retrospective Review of Asian Ectropion: How Does It Compare to Ectropion Amongst Non-Asians?

Introduction: This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes. Materials and Methods: Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Pre- and postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis. Results: Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes. Conclusions: Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians. Keywords: Asian eyes, Lateral tarsal strip

A 5-year retrospective review of Asian ectropion: how does it compare to ectropion amongst non-Asians?

INTRODUCTION

This study reviews the differences in demographics and surgical outcomes between ectropion in Asian and non-Asian eyes.

MATERIALS AND METHODS

Medical records of surgically corrected ectropion cases from January 2002 to December 2006 were reviewed. Preand postoperative lid-globe apposition was graded: grade 0 with normal lid-globe apposition, grade 1 with punctal ectropion, grade 2 with partial lid eversion and scleral show, grade 3 with conjunctival hyperemia and thickening and grade 4 as for grade 3 with exposure keratitis.

RESULTS

Sixty-nine eyes in 50 patients underwent surgical correction of lower lid ectropion, making up 3.3% of all lid procedures performed. Eighty-four percent of patients were above 50 years of age, 72% were males and 88% were Chinese. Involutional change was the commonest aetiology, accounting for the majority of bilateral cases. The mean duration to surgery was 10.0 ± 16.0 months. The most frequent preoperative severity grade was 2. Lateral tarsal strip (LTS) was the commonest procedure performed, comprising 91.3% of eyes. The mean duration of postoperative review was 19.4 ± 19.2 months (range, 1 to 74 months). Postoperative improvement of at least one grade was observed in 98% while normal lid-globe apposition was achieved in 76% of eyes.

CONCLUSIONS

Involutional change is the most common cause of ectropion amongst both Asians and non-Asians. Ectropion is less prevalent amongst Asians as a result of anatomical differences and possibly reduced sun exposure. The LTS procedure is the most commonly performed surgical procedure for the successful correction of ectropion in both Asians and non-Asians.

Asian blepharoplasty--an overview

Asian blepharoplasty has evolved over the years as greater understanding of the differences between the Asian and Caucasian eyelid anatomy has led to the development of modified techniques for upper lid blepharoplasty. The aim of Asian upper blepharoplasty is to create a pleasing and permanent upper lid crease. This article reviews the differences in the anatomy and the various techniques currently employed.

Orbital fibrous dysplasia with soft tissue hamartoma--a variant of Mazabraud's syndrome

BACKGROUND

Mazabraud's syndrome was first described, by Mazabraud et al. as a rare disease, associated with single or multiple intramuscular myxomas with monostotic or polyostotic forms of fibrous dyplasia,

PURPOSE

Reports of this syndrome is rare and usually associated with myoxomatas. The authors would want to report the occurrence of this rare case associated with a hamartoma as basis for record and future studies.

METHOD

An adult male came to the institution 4 years ago complaining of a right unilateral proptosis that he had since childhood. However, proptosis progressed in a month's time accompanied by right eye redness. Right eye was congested with a palpable firm mass on the right lower lid. Best corrected visual acuity was 6/15-2. Pupillary examination revealed the presence of RAPD on the right eye. Exophthalmometry revealed a 10 mm proptosis. EOMS were restricted on the right eye and diplopia was noted in all gazes. Ishihara test showed 14/15 for the right eye. CT SCAN and MRI confirmed a mild inflammatory extraconal or intramuscular mass in the right obito-retrobulbar region. Bony changes seen in the right zygoma, sphenoid bone and squamous part of the temporal bone with extensive bone mineralization. The patient underwent a right lateral orbitotomy with biopsy and debulking of the inferior orbital mass. Histopathology revealed a hamartomatous lesion.

CONCLUSION

Due to the associated soft tissue lesion with multiple craniofacial bone changes, this case may be considered a variant of Mazabraud's Syndrome. The associated hamatomatous lesion may be a rare occurrence that should be noted.

Lacrimal gland amyloidosis

Primary localized lacrimal gland amyloidosis is an extremely rare occurrence. The typical clinical and radiologic appearances have been suggested but not clearly established. This report describes two patients with amyloid tumor of the lacrimal gland. Both patients were middle-aged women of Asian origin, one a Chinese with unilateral lacrimal gland swelling and the other, a Malay with bilateral lacrimal gland swelling. Neither patient had associated systemic disease. They were otherwise asymptomatic except for prominence over the lacrimal gland region. Neither visual impairment nor evidence of optic nerve dysfunction was noted in either patient. CT findings mimic that of an inflammatory or lymphoproliferative disorder of the lacrimal gland. The diagnosis of amyloidosis was only proved on histology. Further investigations revealed that the disease process was truly localized and not part of a systemic process. Subsequent observation proved no recurrence.

Integrated hydroxyapatite implant and non-integrated implants in enucleated Asian patients

INTRODUCTION

This study compares the outcome and complications of integrated hydroxyapatite implant and non-integrated orbital implants following enucleation in Asian patients.

MATERIALS AND METHODS

This is a retrospective study of enucleated patients with coralline hydroxyapatite implants versus non-integrated implants (acrylic, glass and silicone) at the Singapore National Eye Centre from January 1991 to December 2000. The outcomes measured were implant migration, extrusion, socket infection, conjunctival dehiscence and implant exposure. Statistical analysis was done using the 2-sample t-test.

RESULTS

Twenty-one patients had the hydroxyapatite implant and 38 non-integrated implants (27 acrylic, 9 glass and 2 silicone). The mean duration of follow-up was 2.7 years and 4 years for the hydroxyapatite implant and non-integrated implants respectively. Three patients with pre-existing severe socket contracture before enucleation surgeries were excluded from the study. Four cases of implant migration, 4 cases of implant extrusion and 3 cases of socket infection were encountered; all were sockets fitted with non-integrated implants. There was a higher rate of conjunctival dehiscence for sockets with hydroxyapatite implants (6 out of 21) compared to sockets with non-integrated implants (3 out of 35). This was statistically significant (P = 0.048).

CONCLUSIONS

Implant complications of migration, extrusion and socket infection were found in non-integrated implants and none in coralline hydroxyapatite implants, which had a significantly higher rate of conjunctival dehiscence. Most of these were easily managed with only a small number progressing to implant exposure.

Congenital upper lid colobomas: management and visual outcome

PURPOSE

Congenital upper lid colobomas may be associated with ocular and systemic anomalies. The ophthalmologist's role involves both the diagnosis and management of their various ocular structural defects and management of the visual development.

METHODS

All cases of congenital eyelid colobomas referred to the Singapore National Eye Centre between July 1992 and July 1995 were assessed for the extent of the eyelid defect, associated ocular anomalies, status of the cornea, and any systemic anomalies.

RESULTS

Four infants were tested during this period. The mean follow-up was 25 months (range, 16 to 30 months). All required surgical correction of their eyelid defects before 2 years of age. The patients also had refractive errors requiring amblyopia management. Three of the babies also needed other surgical procedures.

CONCLUSIONS

Congenital upper eyelid colobomas are a potential threat to vision at an early age and a significant cosmetic blemish later in life. Early surgical intervention is usually required when the defect is larger than one third of the eyelid margin. Close monitoring of the visual development of patients with congenital upper eyelid colobomas is also essential since the risk of amblyopia in these patients is high.

Lacrimal sac tumour presenting with blood-stained ocular discharge

Malignant epithelial tumours of the lacrimal sac are uncommon. They can mimic chronic dacryocystitis or dacryostenosis to cause a delay in diagnosis. The presence of a medial canthal lump with blood-stained ocular discharge should arouse the suspicion of this diagnosis. The prognosis of lacrimal sac tumour is often guarded especially following tumour recurrence after incomplete resection. We report a patient with squamous cell carcinoma of the lacrimal sac to highlight its presentation and clinical course.

An unusual orbital bone lesion

A case of Langerhans cell histiocytosis involving the left orbital ridge in an 11-year-old girl is reported. The clinical presentation, radiologic findings and histopathological features as well as diagnostic criteria for Langerhans cell histiocytosis are reviewed.

Graves' ophthalmopathy in the absence of elevated free thyroxine and triiodothyronine levels: prevalence, natural history, and thyrotropin receptor antibody levels

The aims of this study were to (a) determine the prevalence of patients without elevated thyroid hormone levels in Graves' ophthalmopathy (GO) using current generation free thyroid hormone assays, (b) measure the prevalence of thyrotropin receptor antibodies (TRAb) in these cases, and (c) identify possible predictors of hyperthyroidism. Over a 30-month period, 1020 cases of thyroid eye disease were evaluated, of which only 19 (1.9%) met the diagnostic criteria. Ten (1%) had subclinical thyrotoxicosis, 7 (0.7%) were euthyroid, and 2 (0.2%) were hypothyroid as determined by a third-generation thyrotropin (TSH) assay. TRAb levels were measured in 16 of these 19 patients. The prevalence of TRAb varied according to the assay used. Polyethylene glycol-extracted thyroid-stimulating immunoglobulin (PEG-TSI), unfractionated thyroid-stimulating immunoglobulin (uTSI), first-generation porcine TSH-binding inhibitory immunoglobulin (pTBII), and second-generation human TSH-binding inhibitory immunoglobulin (hTBII) assays were positive in 93.8%, 50%, 18.8%, and 81.3% of patients, respectively. TRAb was detected by at least one method in all patients. Patients were followed up for 15 to 45 months. Hyperthyroidism developed in 4 patients (25%). Suppressed TSH levels and elevated TBII were predictors of hyperthyroidism. When sensitive assays are used, the prevalence of GO patients without elevated thyroid hormone levels is extremely low. The sensitivities of assays for TRAb detection differ substantially in these cases. PEG extraction improves the detection rate of TSI (p = 0.02), and hTBII assays improve the detection of TBII in these patients (p = 0.002). The high prevalence of TRAb in such cases supports a role for these antibodies in the pathogenesis of thyroid-associated eye disease.

High-pressure paint gun injury to the orbit and ocular adnexa

High-pressure injection injury to the orbit and adnexa is a rare but potentially blinding type of trauma. Few cases of such injury have been reported in the literature. A 27-year-old Indian man accidentally injected paint material from a high-pressure nozzle gun into his left eye. Radiological investigation revealed the presence of paint material in the orbital tissues and the ethmoidal sinuses. The patient underwent two orbital surgeries to remove the paint material. He later developed signs suggestive of limbal stem cell failure and was treated with limbal stem cell autografting. He also has ophthalmoplegia with a compensatory anomalous head posture that was managed conservatively. We report the clinical course and outcome of this unfortunate patient to highlight the complexity of such an injury and the need for a multidisciplinary approach in its management.

The correction of oriental lower lid involutional entropion using the combined procedure

INTRODUCTION

Involutional entropion is a common lid malposition problem in the Chinese geriatric population. The major contributing factors of involutional entropion include disinsertion of the lower lid retractors and horizontal lid laxity. The combined procedure (lower lid retractor repair and lateral tarsal strip procedure) is a useful technique that tackles both the horizontal and vertical aetiologic components of this condition. The surgical technique of this procedure is described and the results and complications presented.

MATERIALS AND METHODS

A retrospective non-randomised study on 41 lower eyelids of 38 Chinese patients. The combined procedure was performed by a single surgeon over a 2 years 11 months period. Nine patients had bilateral lid surgeries. The clinical charts and operative notes were reviewed by an observer.

RESULTS

The mean age of the patients was 74.7 years (range 51 to 92 years). There were 14 males (36.8%) and 24 females (63.2%). The cases were followed up postoperatively for a mean duration of 13 months (range 3 to 48 months). Twelve lids had early postoperative overcorrection but the majority (8 lids) resolved spontaneously with good lid-globe apposition. Of the remaining 4 eyelids, 3 lids had persistent mild asymptomatic ectropion that did not require surgical treatment and only one required re-operation.

CONCLUSION

The combined procedure is an effective means of repair for oriental lower lid entropion with low complication rates.

Surgical management of upper lid epiblepharon

BACKGROUND

Upper lid epiblepharon refers to a developmental anomaly characterised by the presence of an exaggerated skin fold running horizontally across the upper lid below the lid margin, which in severe cases is associated with lash-cornea touch or even corneal punctate epithelial erosions.

METHOD

This retrospective study looked at 14 patients who underwent bilateral upper lid pretarsal orbicularis debulking and skin excision to correct lash-globe contact from the upper lid.

RESULTS

Surgery was successful in 25 of 28 lids, with one recurrence being successfully re-operated. The remaining 2 recurrences did not undergo further surgery as the patients were asymptomatic.

CONCLUSION

This surgical procedure appears to be an effective treatment of lash inversion in upper lid epiblepharon with good aesthetic results.

The use of sodium hyaluronate as a lubricant in brow suspension ptosis surgery using polyester fiber mesh

Polyester fiber is used as an alternative to autologous fascia lata for brow suspension ptosis surgery. The authors found it difficult to pass the polyester compound through the submuscular plane during brow suspension surgery. They used sodium hyaluronate as a lubricant to aid the passage of polyester fiber mesh. In 14 cases of brow suspension surgery with polyester fiber mesh, the authors found sodium hyaluronate to be useful in reducing tissue resistance and without untoward effect.

Using the phacoemulsification crescent knife in dacryocystorhinostomy

Dacryocystorhinostomy is an effective treatment for nasolacrimal duct obstruction. Most techniques employ a conventional blade or knife in making the incision of the nasal mucosa and lacrimal sac. The authors describe the use of a phacoemulsification crescent knife for this purpose. This technique can be effective and at the same time safer and easier to perform.

Hydroxyapatite orbital implants--our local experience

Hydroxyapatite orbital implants were first introduced by Arthur Perry in 1985 and approved by the Food and Drug Administration for general use in 1989. Since its inception, it has become a popular orbital implant as it combines biocompatibility with improved motility. At the Singapore National Eye Centre, twenty consecutive patients underwent hydroxyapatite implantation from June 1993 to June 1996. Seventeen patients who had a follow-up time of more than 6 months were analysed retrospectively. Sixteen had enucleation while one had evisceration performed. The implant size used was either 18 or 20 mm. Seven primary and 10 secondary hydroxyapatite implants were performed in 17 patients ranging in age from 20 to 65 years. Six consisted of coralline hydroxyapatite while the remaining 11 were made of artificial hydroxyapatite. In the follow-up time of 6 to 16 months (mean 10.2 months), there have been no cases of infection, extrusion or migration. Two patients who had implant exposure were managed surgically with fascia lata grafts and have healed well. It appears that hydroxyapatite is the implant of choice for an anophthalmic socket. It becomes incorporated by the patients own tissues and once vascularised, it is less likely to migrate or extrude. The complication rate is low and implant exposure, if it occurs, can be easily managed.

Burkitt lymphoma manifesting as acute proptosis

PURPOSE

To describe an unusual case of Burkitt lymphoma manifesting as acute proptosis and simulating orbital inflammatory disease.

METHODS

Case report.

RESULTS

A 24-year-old Chinese man developed painful severe nonaxial proptosis in his left eye during 1 day. Computed tomographic scan disclosed an orbital mass that was shown to be Burkitt lymphoma when biopsy was performed. The disease progressed rapidly despite chemotherapy.

CONCLUSIONS

Our case supports the fact that Burkitt lymphoma can manifest as acute proptosis and expands the spectrum of clinical presentation of Burkitt lymphoma.