Bryant P. Carruth

Simplified Müller's muscle-conjunctival resection internal ptosis repair.

Purpose: To describe and evaluate a modified technique for blepharoptosis repair via Müller’s muscle-conjunctival resection. Methods: An observational case series is reported. Records of 29 consecutive patients (42 eyelids) with blepharoptosis undergoing internal ptosis repair between January 2008 and December 2010 were reviewed including detailed preoperative and postoperative evaluations, eyelid measurements, surgical outcome, and complications. The procedure performed was a modified Müller’s muscle-conjunctival resection with simple measurements, no traction sutures, a double-opposing mattress suture, and single external knot. Main outcome measures included success of ptosis repair surgery defined by improvement in margin reflex distance, symmetry of upper eyelid position, and incidence of complications. Results: The described modified Müller’s muscle-conjunctival resection procedure achieved improvement in eyelid position in all patients with mean margin reflex distance change of 2.3 mm (p < 0.001). No patient experienced significant complications, and all procedures resulted in objective eyelid symmetry (within 1 mm) and satisfactory cosmetic appearance. Conclusions: The procedure described is an efficient, safe, and successful technique for internal blepharoptosis repair.

Orbital Abscess from Dacryocystitis Caused by Morganella Morganii

ABSTRACT A 22-year-old female with multiple developmental abnormalities stemming from cardiofaciocutaneous syndrome presented with a recurrent orbital abscess 2 years after orbitotomy with drainage of an abscess of presumed hematogenous-origin. During careful intraoperative examination the abscess was seen to directly extend from the lacrimal sac. Cultures were taken and grew Morganella morganii, a Gram negative rod uncommon in ocular and periocular infections. To the author’s knowledge, this microorganism has been reported in only one previous case of orbital abscess and underscores the need for organism identification and antibiotic sensitivity analysis in cases of orbital abscess, particularly those with extension from dacryocystitis.

Inflammatory modulators and biologic agents in the treatment of idiopathic orbital inflammation.

Purpose of review To review the diagnosis and treatment of idiopathic orbital inflammation (IOI), with an emphasis on the development and use of inflammatory mediators and biologic agents. Recent findings Use of targeted biologic immunomodulatory therapy is becoming widespread and proving effective against many inflammatory and autoimmune conditions. Although corticosteroids remain the mainstay of care for IOI, their use is fraught with complications and side-effects, suggesting the need for novel therapies. Evidence for the successful implementation of nonsteroidal inflammatory mediators in IOI is accumulating. Summary The treatment of IOI with traditional methods, particularly corticosteroids, is often inadequate and accompanied by recurrences, medication dependence, and intolerability. Many of these issues may be avoided with the use of existing and novel pharmaceutical agents targeting specific inflammatory mediators. The literature on these agents and their use in IOI is in its infancy but shows tremendous promise in the treatment of this often-recalcitrant illness.

Extreme Eyelid Lymphedema Associated with Rosacea (morbihan Disease): Case Series, Literature Review, and Therapeutic Considerations

PURPOSE To describe severe lymphedema of the eyelids, known as Morbihan disease, a previously characterized but infrequently reported and poorly understood entity related to rosacea that features solid mid-facial and eyelid lymphedema. METHODS Retrospective chart review, histopathologic and immunohistochemical analysis, and pertinent literature consideration. RESULTS Five cases of Morbihan disease were identified. Histopathologic examination revealed pleomorphic perivascular and perilymphatic inflammation with profound lymphangiectasis and lymph stasis, thus suggesting elements of both rosacea and localized, chronic lymphedema. Multiple therapeutic interventions were performed including systemic anti-inflammatory therapy, surgical debulking, and corticosteroid injection. CONCLUSIONS Extreme eyelid edema associated with characteristic skin changes and histopathologic findings represents an entity known as Morbihan disease which is rare and difficult to treat. While multiple modalities have been employed with variable results, future therapeutic considerations may include the use of targeted biologic agents.

Linear IgA bullous dermatosis: an unusual cause of upper eyelid cicatricial entropion.

Chronic cicatrizing conjunctivitis is a relatively uncommon condition resulting in significant ophthalmic morbidity, including keratoconjunctivitis sicca, cicatricial entropion, trichiasis, corneal scarring, significant discomfort, and visual loss. The potential causes of cicatrizing conjunctivitis are varied and include commonly encountered entities such as ocular cicatricial pemphigoid, Stevens-Johnson syndrome, and trachoma and many more rare causes which are particularly difficult to diagnose and treat and may not be familiar to the ophthalmologist. The authors herein present a case of chronic cicatrizing conjunctivitis, cicatricial entropion, and trichiasis caused by a rare entity called linear IgA bullous dermatosis. The case presentation conforms to the tenets of the Declaration of Helsinki and is Health Insurance Portability and Accountability Act compliant. This chronic dermatosis has a varied presentation, and the ophthalmic manifestations in particular have been infrequently described. This case demonstrates the benefits of immunohistochemistry in diagnosis and the difficulties in medical and surgical management of linear IgA bullous dermatosis while underscoring the lifelong difficulties in managing chronic inflammatory conditions causing ocular cicatrization.

Visual improvement after optic nerve sheath decompression in a case of congenital hydrocephalus and persistent visual loss despite intracranial pressure correction via shunting.

Among the sequelae of persistent raised intracranial pressure (ICP) are ophthalmologic signs and symptoms, including cranial nerve palsies, visual field deficits, papilledema, and vision loss. Elevated pressure within the optic nerve sheath may not be relieved by shunt procedures, which can decrease generalized ICP. The authors present a case of acute visual loss in the setting of chronic hydrocephalus and multiple shunt revisions. Despite shunt correction resolving systemic symptoms of raised ICP, this child had persistent visual loss. Bilateral optic nerve sheath decompression was performed, and the visual acuity improved over the next 3 days. This case highlights the importance of routine ophthalmologic examination in patients with hydrocephalus and shunts and demonstrates the utility of optic nerve sheath decompression as a surgical intervention when shunting alone does not resolve visual loss.

Primary adnexal angiosarcoma masquerading as periorbital hematoma

We report an elderly woman who was anticoagulated and presented with a recent history of right-sided orbital contusion and a periorbital hematoma without clinical or radiological evidence of focal mass or orbital involvement. She was initially treated conservatively. Continued progression of adnexal swelling and erythema prompted further investigation, however. There was no improvement with surgical drainage alone; biopsy revealed angiosarcoma. The discovery of this vascular tumor underscores the importance of a reconsideration of the diagnosis in the face of counterintuitive findings. Additionally, we emphasize the need to consider malignancy in the differential diagnosis of prolonged periorbital swelling, regardless of a history of recent trauma.

Nontraumatic subperiosteal bilateral orbital hemorrhages after mitral valve repair.

Nontraumatic subperiosteal orbital hemorrhages (NTSOHs) are rare events, but pose a grave risk of vision loss and must be evaluated carefully for optic nerve compromise. To the authors knowledge, only 2 cases of NTSOH after cardiovascular procedures have been reported. The authors report a unique case of bilateral NTSOH with optic neuropathy that developed after cardiothoracic surgery and reaccumulated after orbitotomy. The case presentation conforms to the tenets of the Declaration of Helsinki and is Health Insurance Portability and Accountability Act compliant. The etiology and management of this uncommon and dangerous entity will be discussed.

Ocular and Orbital: Viewpoint—Surgery

The bony orbit surrounding the eye is a unique anatomic space and is affected by similarly unique pathologic processes. These tumors and diseases may be amenable to stereotactic radiation; however, often they require surgical intervention commensurate with the distinctive nature of the anatomy and pathology. Tumors and inflammatory lesions of the orbit frequently require incisional biopsy to establish a diagnosis, while other masses may be excised entirely. These surgeries require very particular approaches to achieve the objective while protecting the eye and other important structures. Specifics regarding approaches to orbital surgery will be discussed below. Also discussed will be another surgery unique to the orbit termed enucleation or removal of the eye when it becomes blind and painful or is invaded by tumor. Some other ophthalmic diagnoses have been suggested in the past as targets for stereotactic radiosurgery, and these will be discussed as well. The high concentration of integral structures within the orbit confounds both surgical and radiotherapeutic approaches to many lesions and diseases. Given the small margin for error, stereotactic radiosurgery may prove to be a very useful adjunct to orbital surgery, and early experiences combining the expertise of orbital surgeons, neurosurgeons, and radiation oncologists have been encouraging.