Flora Levin

Excision of Periocular Basal Cell Carcinoma With Stereoscopic Microdissection of Surgical Margins for Frozen-Section Control: Report of 200 Cases

OBJECTIVE To report our experience with 200 cases of basal cell carcinoma (BCC) in 192 patients treated with an enhanced frozen-section control (FSC) technique using stereoscopic microdissection of surgical margins. METHODS Retrospective series of 192 patients with 200 lesions diagnosed as BCC of the periocular region. All were excised en bloc with 1-mm margins beyond the clinically apparent tumor and examined using an enhanced FSC technique with stereoscopic microdissection of the surgical margins. RESULTS Of 200 malignant BCCs, 93.0% represented primary tumors. The overall recurrence rate was 1.0%, with a mean follow-up of 4 years. In patients with primary lesions, the overall recurrence rate was 1.1%, with a mean follow-up of 3.9 years. There were no recurrences in the secondary tumor group after a mean follow-up of 4.8 years. Of the 200 lesions, 66.0% lesions required a single en bloc resection to achieve tumor-free margins. CONCLUSIONS An enhanced FSC technique using stereoscopic microdissection of the surgical margins permits greater conservation of healthy tissue and yields cure rates comparable to those of the standard FSC technique and Mohs micrographic surgery. We believe that this enhanced FSC technique is a highly effective method for resection of periocular BCC.

Acellular human dermal matrix as a skin substitute for reconstruction of large periocular cutaneous defects.

Purpose: To describe our experience using acellular human dermal matrix (AlloDerm) as a full-thickness skin graft substitute for large periocular cutaneous defects. Methods: Retrospective review of the clinical records of all patients who received an acellular dermal allograft between 1997 and 2006 to reconstruct a large periocular cutaneous defect. Clinical outcomes, including graft viability, patient acceptance, and postoperative appearance, were assessed, and complications were noted. Results: AlloDerm was used in 6 patients who were not ideal candidates for autologous skin grafts or local flap reconstruction. Four patients had severe comorbid conditions limiting the extent of surgery that could be performed safely. Four patients received AlloDerm following excision of extensive skin cancer. Two patients had extensive facial and periorbital trauma necessitating rapid defect closure at the time of primary repair. Follow-up ranged from 6 to 33 months. AlloDerm was easy to handle and shape, and it effectively covered the defects. Grafts were successfully epithelialized in all patients. One patient required a full-thickness skin graft 3 months following the original surgery for a cicatricial ectropion. No other postoperative complications were noted. Postoperative photographs demonstrated acceptable cosmetic appearance after epithelialization was complete. Conclusions: In patients for whom large full-thickness periorbital skin grafts or flaps are either inappropriate or extremely difficult to perform, the use of AlloDerm to cover a large cutaneous defect may be a viable option. Clinicians should consider covering large periorbital skin defects with AlloDerm in situations where autologous skin grafting or flap construction may be problematic or where extensive surgery may be hazardous to the patient.

Electromagnetic image-guided orbital decompression: technique, principles, and preliminary experience with 6 consecutive cases.

Abstract Purpose: To assess the feasibility of routine use of electromagnetic image guidance systems in orbital decompression. Methods: Six consecutive patients underwent stereotactic-guided three wall orbital decompression using the novel Fusion ENT Navigation System (Medtronic), a portable and expandable electromagnetic guidance system with multi-instrument tracking capabilities. The system consists of the Medtronic LandmarX System software-enabled computer station, signal generator, field-generating magnet, head-mounted marker coil, and surgical tracking instruments. In preparation for use of the LandmarX/Fusion protocol, all patients underwent preoperative non-contrast CT scan from the superior aspect of the frontal sinuses to the inferior aspect of the maxillary sinuses that includes the nasal tip. Results: The Fusion ENT Navigation System (Medtronic™) was used in 6 patients undergoing maximal 3-wall orbital decompression for Graves’ orbitopthy after a minimum of six months of disease inactivity. Preoperative Hertel exophthalmometry measured more than 27 mm in all patients. The navigation system proved to be no more difficult technically than the traditional orbital decompression approach. Conclusion: Electromagnetic image guidance is a stereotactic surgical navigation system that provides additional intraoperative flexibility in orbital surgery. Electromagnetic image-guidance offers the ability to perform more aggressive orbital decompressions with reduced risk.

Bilateral Corneal Perforations and Autoproptosis as Self-Induced Manifestations of Ocular Munchausen's Syndrome

Purpose: To report a patient with bilateral corneal perforations and autoproptosis in a case of ocular Munchausen’s syndrome. Design: Case report. Participant: A 26-year-old white male referred to the oculoplastics service with one month history of decreased vision bilaterally and painful right eye. Multiple eyelid scars and right corneal opacity were noted. The patient was previously seen at another institution for rapid loss of vision in both eyes. Interventions: An orbit decompression among many procedures failed to controlled extreme pain and proptosis. Main Outcome Measures: Resolution of proptosis, stabilization of vision, pain resolution. Results: Three weeks after enucleation of the right eye was offered, patient presented with spontaneous left ruptured globe. After multiple episodes of self-mutilation and infections, both eyes were exenterated. Conclusions: Munchausen syndrome can be seen with ophthalmic manifestations and should be considered in the differential diagnosis when ocular abnormalities cannot be explained after a thorough evaluation. Recognition of this psychiatric disease is not only important for correct medical diagnosis and treatment, but also essential in protecting the patients from unnecessary invasive and aggressive medical procedures.

Dilated Superior Ophthalmic Vein: Clinical and Radiographic Features of 113 Cases.

PURPOSE Dilated superior ophthalmic vein (SOV) is an uncommon radiographic finding. The authors review the presentation, etiology, radiography, and visual implications of 113 patients with dilated SOV. METHODS An observational case series and multicenter retrospective chart review were conducted. There were 113 patients with a dilated SOV. Outcome measures included patient demographics, clinical features, radiographic findings, diagnosis, and treatment, and treatment outcomes were assessed. RESULTS Cases included 75 women (66%) and 38 men (34%) with a mean age of 49 ± 24 years (range, 0.4-90 years). Diagnoses fell under 6 categories: vascular malformation (n = 92, 81%), venous thrombosis (n = 11, 10%), inflammatory (n = 6, 5%), traumatic hemorrhage (n = 2, 2%), lymphoproliferative (n = 1, 1%), and infectious (n = 1, 1%). Imaging modalities utilized included MRI (n = 98, 87%), digital subtraction angiography (n = 77, 68%), CT (n = 29, 26%), and ultrasonography (n = 4, 4%). Disease status at last follow up included no evidence of disease (n = 57, 50%), alive with persistent disease (n = 53, 47%), and expired from disease (n = 3, 3%). Treatment and management was tailored to the underlying disease process with a mean follow up of 18 months (range, 1 day to 180 months). Visual impairment observed at presentation and last follow up across all cases was 26% and 22%, respectively. CONCLUSION Dilated SOV is a rare radiographic finding resulting from a wide spectrum of etiologies with clinical implications ranging from benign to sight- and life-threatening. Dilated SOV is most often found with dural-cavernous fistula or carotid-cavernous fistula, orbital or facial arteriovenous malformation, and venous thrombosis. Recognition of this finding and management of the underlying condition is critical.

Periocular Melanoma In Situ Treated With Imiquimod.

Purpose: To evaluate the efficacy of topical 5% imiquimod cream in the treatment of periocular melanoma in situ (lentigo maligna). Design: Retrospective case series. Subjects: There were 12 patients in this series, and the mean patient age was 77 years. The anatomical locations were the lower eyelid (n=5), upper and lower eyelid (n=4), lower eyelid including the eyelid margin (n=1), brow (n=1), and the medial canthus (n=1). Topical 5% imiquimod cream was used as a primary treatment (n=6) or as an adjunctive therapy following local excision (n=2), cryotherapy (n=2), or excisional biopsy with cryotherapy (n=2). Methods: Twelve patients with periocular melanoma in situ were treated with topical 5% imiquimod cream daily for a mean treatment period of 3.9 months. The clinical features of the patients and the responses to treatment were evaluated in a retrospective case series. Main Outcome Measures: Histologic clearance of atypical melanocytes. Results: Eleven patients achieved complete histologic clearance of atypical melanocytes on post-treatment biopsy. One patient could not tolerate local irritation from imiquimod and stopped in the first month of therapy with residual disease. The median follow-up time was 1.5 years. Side effects included redness (n=12), discomfort (n=6), swelling (n=4), ectropion (n=1), and conjunctival chemosis (n=1). The patients experienced no systemic side effects from the treatment. Conclusions: Topical 5% imiquimod cream is an effective option as primary or adjunct therapy in the treatment of periocular melanoma in situ.

Periocular Necrotizing Fasciitis Causing Blindness

IMPORTANCE Periocular necrotizing fasciitis is a rare but potentially devastating disease, accompanied by high rates of morbidity and mortality. OBSERVATIONS We report 5 cases of periocular necrotizing fasciitis resulting in severe vision loss, 3 of which required exenteration to contain the disease and only 1 of which recovered vision. Three cases were caused by group A streptococcus; 1, by methicillin-resistant Staphylococcus aureus; and 1, by Streptococcus anginosus constellatus. CONCLUSIONS AND RELEVANCE Providers should maintain a high clinical suspicion for necrotizing fasciitis and distinguish it from more common forms of cellulitis. As seen in these 5 cases, periocular necrotizing fasciitis may cause severe visual loss more often than previously recognized. To our knowledge, this is also the first report of Streptococcus anginosus constellatus causing necrotizing fasciitis.

Periocular abscesses following brow epilation.

Purpose: The aim of this article was to report the clinical presentation, radiography, culture results, treatment modalities, and outcomes of periocular abscesses associated with brow epilation. Methods: This was a retrospective case series including 26 patients referred for periocular abscess following brow epilation. Results: Twenty-six female patients with a median age of 20.5 (range, 12–73) years were referred for oculoplastic evaluation of periocular abscesses related to recent brow epilation. All patients were treated with incision and drainage along with systemic antibiotics. Culture results revealed 16 cases of methicillin-resistant Staphylococcus aureus, 3 of methicillin-sensitive Staphylococcus aureus, and 7 cultures that showed no growth. All patients had resolution of their abscesses at 1-month follow-up visits without progression to orbital cellulitis. Conclusions: Periocular abscess formation after brow epilation has been previously described in only a single case report in the literature. The authors believe this entity is underreported given their current report describing 26 such cases. Given the high prevalence of cosmetic brow epilation in females, the authors believe a careful history regarding brow epilation in any patient presenting with a periocular abscess or preseptal cellulitis is essential to explore the possible cause of their infection. The majority of patients in the current study’s cohort had methicillin-resistant Staphylococcus aureus-related abscesses, and treatment with antibiotics with methicillin-resistant Staphylococcus aureus coverage may be a prudent first line choice in such patients.

Clinical Parameters and Outcomes in Periorbital Necrotizing Fasciitis.

Purpose: To describe the clinical features associated with periorbital necrotizing fasciitis and to correlate these features with clinical outcomes. Methods: The case logs of 3 surgeons were used to identify cases of necrotizing fasciitis. Chart reviews were performed to characterize clinical metrics, and statistical analyses were performed. Results: Seventeen patients (9 males, 8 females; mean age = 48.1 years, standard deviation = 22.6 years) were identified with periorbital necrotizing fasciitis. Of these patients, 52.9% did not have immunodeficiencies, and 52.9% did not have antecedent trauma or infected facial lesions. One patient died from necrotizing fasciitis. A history of immunosuppression correlated with the requirement for exenteration, but did not correlate visual acuity of worse than 20/40 upon discharge from the hospital. Most of the patients (68.75%) were discharged with visual acuity of better than 20/40 in the affected eye. Conclusions: This study represents the largest case series of patients with periorbital necrotizing fasciitis. Most of the patients in this series did not have immunodeficiencies, and the majority were discharged with favorable visual acuities. Nonetheless, a history of immunosuppression correlated with the need for exenteration, but was not statistically linked with worse visual outcomes.

Spontaneous Periocular Ecchymosis in Children: Differential Diagnosis and Current Trends in Evaluation and Management

While periocular ecchymosis commonly develops following surgery or traumatic injury to the orbit, the spontaneous appearance of periocular ecchymosis in children can indicate the presence of life-threatening conditions including pediatric malignancies (neuroblastoma, rhabdomyosarcoma, leukemia) and hematologic disorders (aplastic anemia, thrombocytopenia). Vascular malformations (capillary hemangioma, lymphangioma, orbital varix), inflammatory conditions (orbital myositis, amyloidosis), pertussis, and Blue rubber bleb nevus syndrome are benign differential considerations with visual complications in certain instances. Since spontaneous periocular ecchymosis (SPE) can be encountered by pediatric subspecialists both within and outside ophthalmology, the authors present a review of the current literature integrating the clinical features, latest diagnostic investigations, and updates in management for the entities that cause spontaneous periocular ecchymosis in children. A comprehensive and current understanding of the differential diagnosis elicited by this unique ocular finding will aid the clinician in managing long-term visual consequences and coordinating with appropriate pediatric subspecialists.