Allen M. Putterman

MR imaging of orbital inflammatory syndrome, orbital cellulitis, and orbital lymphoid lesions: the role of diffusion-weighted imaging.

BACKGROUND AND PURPOSE: Orbital inflammatory syndrome (OIS) has clinical features that overlap with orbital lymphoid lesions and orbital cellulitis. Prompt diagnosis is needed in all 3 conditions because the management of each one differs greatly. CT and MR imaging, though useful, do not always distinguish among these conditions. The aim of this study was to identify the role of diffusion-weighted imaging (DWI) in differentiating these 3 diagnoses. MATERIALS AND METHODS: A retrospective analysis of orbital MR imaging was conducted. T1- and T2-weighted and postcontrast images were analyzed. Region-of-interest analysis was performed by using measurements in areas of abnormality seen on conventional MR imaging sequences and measurements of the ipsilateral thalamus for each patient. The DWI signal intensity of the lesion was expressed as a percentage of average thalamic intensity in each patient. Similarly, lesion apparent diffusion coefficients (ADCs) and lesion-thalamus ADC ratios were calculated. Statistical significance was determined by the Kruskal-Wallis test, and post hoc pairwise comparisons, by the Mann-Whitney U test for DWI-intensity ratio, ADC, and ADC ratio. RESULTS: A significant difference was noted in DWI intensities, ADC, and ADC ratio between OIS, orbital lymphoid lesions, and orbital cellulitis (P < .05). Lymphoid lesions were significantly brighter than OIS, and OIS lesions were significantly brighter than cellulitis. Lymphoid lesions showed lower ADC than OIS and cellulitis. A trend was seen toward lower ADC in OIS than in cellulitis (P = .17). CONCLUSIONS: DWI may help differentiate OIS from lymphoid lesions and cellulitis and may allow more rapid management.

Silicone intubation for the treatment of congenital lacrimal duct obstruction: successful results removing the tubes after six weeks.

There is little agreement in the ophthalmic literature on the optimum length of time that silicone tubes should be left in place after lacrimal intubation for the treatment of congenital nasolacrimal duct obstruction. Various authors have recommended leaving the tubes in for 3 to 6 months. The authors of this article believe this to be an excessive amount of time. Lacrimal probing, inferior turbinate fracture, and silicone intubation were performed in children ranging in age from 3 months to 5 years. The tubes were removed after 6 weeks in all cases. Resolution of epiphora and dacryocystitis was achieved in all cases. Follow-up ranged from 4 to 81 months. The authors recommend that the silicone tubes be removed after 6 weeks. They also believe that fracture of the inferior turbinate should be performed along with silicone intubation.

IMAGING OF ORBITAL LYMPHOPROLIFERATIVE DISORDERS

Lymphomas and leukemias account for a large portion of orbital tumors. Orbital lymphoma accounts for 55% of malignant orbital tumors in adults. Idiopathic orbital inflammatory pseudotumors are pathologic entities that often challenge ophthalmologists and radiologists. This article describes the MR and CT features of orbital lymphoma, leukemia, and some other lymphoproliferative disorders.

Frozen Section Control in the Surgery of Basal Cell Carcinoma of the Eyelid

Two groups of patients, 37 with primary basal cell carcinoma of the eyelid and 16 with basal cell carcinoma of the eyelid previously treated by other physicians were reviewed. All of the tumors were excised with at least 3 to 4 mm of normal-appearing tissue at each margin of resection. All of the excised specimens were submitted for frozen section studies of the margins. A total of 20 (54.04%) of the previously untreated tumors and eight of the previously treated tumors had at least one margin involved with tumor cells. Repeated excisions under frozen section control were done until all of the margins were free of tumor cells. To date, none of the patients treated in this manner had a recurrence of the tumor.

Conjunctival map biopsy to determine pagetoid spread

Sebaceous adenocarcinoma (meibomian gland cancer) can be localized at times to one specific area of the eyelid; at other times, it spreads diffusely by pagetoid invasion throughout the conjunctiva. The pagetoid spread is often impossible to visualize. I used a map biopsy of the conjunctiva to determine the extent of involvement of sebaceous adenocarcinoma in 12 patients. Sixteen conjunctival biopsy specimens were taken from various areas of the palpebral and bulbar conjunctiva. An analysis of these specimens helped to delineate the area of tumor involvement, which aided in determining whether to treat these cases by full-thickness eyelid resection or orbital exenteration.

Müller's muscle in the treatment of upper eyelid ptosis: a ten-year study.

Müllers muscle is a sympathetically innervated muscle that can be resected to treat upper eyelid ptosis. Candidates for the ptosis procedure are those whose upper lids elevate to a normal level following instillation of phenylephrine hydrochloride drops into their upper ocular fornix. A specially designed clamp is applied to 6.5 to 9.5 mm of conjunctiva and Müllers muscle above the superior tarsal border. A suture is run distal to the clamp, connecting conjunctiva and Müllers muscle to the superior tarsal border; then, the tissues held in the clamp are resected. In a ten-year study of this procedure, 90% of the lids with acquired ptosis and 100% of those with congenital ptosis were within 1.5 mm of the level of the opposite lid postoperatively. Only two of 232 treated lids required additional surgery.

Viable Composite Grafting in Eyelid Reconstruction

I reconstructed eyelids in two patients by successfully using a new technique to increase the viability of a composite, full-thickness eyelid graft. Splitting the graft into two components of tarsal-conjunctival-margin and skin and placing each component against a viable skin and orbicularis flap, respectively, facilitated the acceptance of the graft and increased the success of the reconstruction.

Temporary Blindness after Cosmetic Blepharoplasty

A patient who underwent a cosmetic blepharoplasty suffered a retrobulbar hemorrhage with no light perception deception detected when the dressing was removed two hours postoperatively. Opening the incision site led to the complete return of visual acuity and ocular motility and relief of the proptosis. The rebleeding of cauterized blood vessels may have caused the retrobulbar hemorrhage and seems to be a potential problem in all cosmetic blepharoplasties. Eliminating the use of postoperative bandages may prevent blindness after cosmetic blepharoplasty since it allows early detection of a retrobulbar hemmorrhage. This allows the nurse to check the patient for loss of vision and proptosis at ten-minute intervals for the first two hours after surgery so immediate treatment can be implemented if retrobulbar hemorrhage and central retinal artery occlusion occur.

Prolapse of the Globe into the Maxillary Sinus after Orbital Floor Fracture

A 24-year-old woman sustained a blow-out fracture of the orbital floor with prolapse of the globe into the maxillary sinus. This was treated by replacing the globe in the orbit surgically and reconstructing the orbital floor. Postoperatively, the eye retained normal visual acuity.

A Clinicopathologic Study of Hematic Cysts of the Orbit

Hematic cyst of the orbit has been described in association with various diseases, but its pathogenetic mechanism remains unclear. We treated two patients (two men, 38 and 35 years old) who had growing cysts suspected of being malignant tumors. Surgical exploration of the orbits disclosed birefringent crystals (hematodin) either in the cyst wall or in the cysts contents. The crystals imitated foreign bodies in their appearance and in the reactions they induced.