Arie Y. Nemet

Orbital exenteration: a 15-year study of 38 cases.

Purpose: To determine the clinical indications and outcomes after orbital exenteration when histologic margins were reported as “clear,” examining factors affecting local and systemic recurrences and mortality. Methods: Retrospective case review of exenterations performed in Sydney Eye Hospital in Sydney, Australia, between 1990 and 2004. Reviewed data indications for exenteration, histopathologic diagnosis, and recurrences on follow-up. Results: Secondary intraorbital spread of malignant adnexal tumors was the most common indication for exenteration (34 of 38). Among these, the site of the primary neoplasm was the eyelid in 19 cases and the ocular surface in 12 cases. Exenteration was total in 26 cases, subtotal in 8 cases, and extended in 4 cases. In 11 cases, a dermis-fat graft was used for socket reconstruction; 24 cases were allowed to granulate spontaneously. The average healing time was 5 months (range, 4–6 months) for spontaneous granulation, and 6 weeks (range, 4–8 weeks) for dermis-fat grafts. Perineural spread was demonstrated histopathologically in 7 specimens. During follow-up (median, 48 months), there were 9 recurrences (23.7%): 3 local and 6 systemic. Seven patients (18.4%) died of the disease during the follow-up period. Conclusions: Dermis-fat grafts for reconstruction of the exenterated socket seem to optimize the aesthetic results. The first year is the most important period for follow-up of local recurrences, but systemic examination is needed for the longer follow-up. This may have implications in terms of reconstruction and adjunctive treatment following exenteration surgery.

Interferon alpha 2b treatment for residual ocular surface squamous neoplasia unresponsive to excision, cryotherapy and mitomycin-C.

Three patients had residual or recurrent tumour following excision of large ocular surface squamous neoplasia (OSSN) lesions, which did not resolve despite the use of adjunctive cryotherapy and topical mitomycin‐C therapy. The residual tumour was treated with topical or subconjunctival injectable interferon α 2b. All three eyes had complete resolution of the OSSN lesions after an average of 6u2003weeks (range 4–8u2003weeks) of treatment with interferon α 2b. No regrowth was seen during the follow‐up period of 22.7u2003±u200332.3u2003months (range 5–60u2003months). No adverse reactions or complaints were reported during and following interferon use, and previous symptoms from mitomycin‐C treatment resolved completely. In these patients subconjunctival or topical interferon was an effective and safe treatment for residual OSSN. Longer follow up is required to confirm the long‐term efficacy in prevention of recurrences.

The lateral triangle flap--a new approach for lateral orbitotomy.

Lateral orbitotomy with or without removal of the lateral wall enables access to the extraconal and intraconal spaces of the orbit lateral to the optic nerve. We present the lateral triangle flap technique using an upper eyelid skin crease incision and skin incision from the lateral canthal angle joining together laterally at the outer margin of the lateral orbital rim, just beyond the lateral orbital margin. A triangular skin muscle flap is raised medially, based at the canthal angle, providing maximal exposure of the lateral and superolateral orbital wall. The deep lateral orbital wall can be burred away for lateral orbital decompression, or a bone flap removed for exposure of deep intraconal or extraconal lesions. The lateral triangle flap provides excellent exposure and postoperative cosmetic results.

Orbital invasion of frontal sinus lymphoma.

Paranasal sinus lymphoma is an uncommon malignancy and is often difficult to diagnose. Early diagnosis is essential for effective treatment. The tumour generally has poor prognosis. Ophthalmological symptoms and signs occur early in the disease process due to the close proximity of the orbit to the paranasal sinuses. Common presenting features include eye pain, proptosis, visual loss and diplopia. We report a case of frontal sinus lymphoma that presented as a superior-nasal orbital mass in an 84 year old man. CT scan demonstrated a mass occupying the frontal sinuses, with destruction of the anterior bony wall of the frontal sinus and extending to the right orbit. Histology revealed diffuse large B cell non Hodgkins lymphoma. The tumor was treated with radiotherapy and showed regression; however the patient died 9 months later. Sinus tumours are encountered by ophthalmologists and should be considered in patients presenting with an orbital mass.

LESCs: Lateralizing Eyelid Sleep Compression Study.

Purpose: To study the hypothesis that in normal patients, changes in eyelid elasticity may occur asymmetrically and in relation to the side on which the individual sleeps. Design: Prospective, consecutive, single-center study within a large, tertiary-referral ophthalmology department within a university hospital. Methods: This prospective study was carried out consecutively on 262 normal patients. The 3 inclusion criteria were 1) age ≥55 years, 2) absence of facial nerve palsy, and 3) absence of eyelid trauma or surgery. Immediately before the ocular plastic surgeon assessed the patient, each patient was questioned in a separate consulting room by the attending orthoptist as to his or her customary side of sleeping. After detailed explanation, the “history-masked” ocular plastic surgeon then assessed the patient’s upper eyelid laxity, the main outcome measurement. This was performed by asking the seated patient to look down and then gently grasping the upper eyelids close to the eyelid margin, just medial to the lateral commissure. The ocular plastic surgeon, with thumbs pronated, simultaneously distracted both upper eyelids superiorly, laterally, and anteriorly. The measured separation of the upper eyelid from the globe conjunctiva was obtained using calipers. Eyelid laxity grading was designated as grade 1: 0 to 1.9 mm; grade 2: 2.0 to 3.9 mm; grade 3: 4 to 9 mm; and grade 4: floppy. Results: Two hundred sixty-two patients (58% females) who consecutively satisfied the selection criteria were evaluated, of which 70.22% (183/262) patients had significantly greater laxity of the upper eyelid that corresponded to the side on which they customarily slept. An unpaired t test used to compare the eyelid laxity between the sleeping side and nonsleeping side was statistically significant (p < 0.001). Conclusion: Normal patients demonstrate a correlation between the side on which they historically or customarily sleep and the laxity of their ipsilateral upper eyelid.

Peripunctal "anchor" suture for securing the silicone bicanalicular stent in the repair of canalicular lacerations.

We used punctal absorbable suture in 8 patients (8 eyes) for silicone stent stabilization in canalicular repair surgery to prevent the postoperative complication of “cheese-wiring.” Postoperatively there was 1 case of cheese-wiring of the repaired canaliculus, and no other complication related to the bicanalicular stent. The pericanalicular “anchor” suture may reduce the incidence of cheese-wiring by silicone bicanalicular stents after repair of canalicular lacerations or resections for stenosis.

A 7th Nerve Palsy in a Child with Langerhans Histiocytosis

A 7-year-old girl developed an osteolytic soft tissue mass extending into the right orbital floor and maxillary sinus which was confirmed to be Langerhans cell histiocytosis. Partial lower motor 7th nerve palsy had developed, likely due-to a combination of local swelling from the tumour and the steroids.

Unilateral Poliosis of Eyelashes.

A 68-year-old man presented with significant, asymptomatic, unilateral eyelash poliosis, not associated with any ophthalmic or systemic conditions. He reported that this started about 40 years ago with a few lashes in the central portion of his eyelid and that adjacent eyelashes subsequently became involved over the next 4 to 5 days. He had normal ophthalmologic and neurologic examinations with no other relevant medical history reported. The case might be an unusual presentation of a halo nevus. To the best of the authors knowledge, this is the first such case reported regarding the eyelashes. The case and relevant literature are presented.

Massive Recurrent Chalazion With Anterior Orbital Extension.

A 14-year-old girl developed a large, asymptomatic lump on the right lower eyelid a few weeks after chalazion excision. MRI showed a very large, elliptical, postseptal lesion 1.8u2009×u200914.1u2009×u200921.2u2009mm which intensified homogeneously with gadolinium. The patient underwent orbital biopsy of the lesion using a swinging eyelid approach. A dense, solid, nondraining encapsulated lesion was palpated and separated from the surrounding tissue. Histopathologic diagnosis was a granulomatous chalazion.