Francis C. Sutula

Eyelid Necrosis Following Intralesional Corticosteroid Injection for Capillary Hemangioma

The intralesional injection of corticosteroids has been employed successfully in treatment of adnexal neonatal hemangiomas since 1979. This form of treatment is easily administered, is repeatable and free from serious complications. We present an exceptional case in which full-thickness eyelid necrosis ensued following intralesional injection of corticosteroids in a capillary hemangioma. After eyelid reconstruction the patients visual axis has remained unobstructed, and amblyopia has been thus far averted.

Congenital Nasolacrimal Duct Obstruction

Congenital nasolacrimal duct obstruction affects up to 20% of all newborns. Affected children will present with epiphora, chronic or recurrent conjunctivitis, or eye discharge, which may progress to frank cases of acute dacryocystitis. Management ranges from watchful waiting to probing to probing with Silastic intubation to dacryocystorhinostomy. It is important to understand the lacrimal drainage anatomy, its embryological development, and the natural course of this condition so as to make an informed decision about the management of congenital nasolacrimal duct obstruction.

Sclerosing orbital pseudotumor.

We report two patients who underwent orbital exploration yielding the diagnosis of sclerosing orbital pseudotumor. The presenting symptoms were exophthalmos, visual loss, abnormal ocular mobility, and ocular pain. Computed tomographic (CT) scans showed masses in the orbital apex. Steroids were ineffective. Orbital pseudotumor is a heterogeneous diagnostic category of lymphoid infiltrations of the orbit with a wide spectrum of pathological conditions and intraorbital locations. The clinical presentation typically includes the sudden onset of pain, diplopia, lid edema, and exophthalmos. Visual loss is uncommon. Most cases resolve spontaneously or respond to steroid treatment. Although fibrosis may be a prominent histological finding, the literature contains little information concerning its significance. We discuss the evidence for considering the sclerosing pseudotumors to be a significant variant with unique clinical behavior. Although features suggestive of pseudotumor were present in our case, the presence of visual loss and an apical mass shown on the CT scan led to the presumptive diagnosis of tumor and exploratory operation. Neurosurgeons should be aware of this entity as a cause of visual loss and orbital mass. Proper suspicion may in some cases permit transorbital biopsy and avoid craniotomy, inasmuch as operation is of no therapeutic benefit in this disease.

Histological changes in congenital and acquired blepharoptosis.

Histological specimens of eyelids from patients with congenital genuine ptosis and acquired involutional ptosis are compared. In congenital ptosis there is evidence of true muscular dystrophy of the levator muscle as demonstrated by: loss of cross striations, random decrease in muscle fibre diameter, sarcolemmal retraction, nuclei alignment, and fibrous and fatty tissue displacement of the striated fibres.In involutional ptosis disinsertion of the levator aponeurosis from its normal insertion on the inferior-anterior surface of the tarsus is demonstrated. Correlation between clinical presentation and surgical correction is explained in light of these findings.

Solitary extramedullary plasmacytoma of the palpebral conjunctiva.

A 63-year-old man had a solitary extramedullary plasmacytoma of the conjunctiva for several years with no history of ocular inflammation or systemic abnormalities. Immunoperoxidase staining was consistent with a neoplastic lesion. This is the only well documented such case in the recent literature to the best of our knowledge. This rare condition is contrasted with reactive plasma cell granuloma, a benign inflammatory condition, which comprises most of the cases previously reported as plasmacytomas. Since extraskeletal plasmacytomas may be the first manifestation of multiple myeloma, these patients deserve appropriate diagnostic evaluation and close follow-up.

Angiosarcoma of the eyelid: Yellow plaques causing ptosis

Angiosarcomas are aggressive malignant tumors of vascular origin that may originate anywhere in the body. They occur most commonly on the head and neck region of elderly men. 1-3 The tumors usually present as bruiselike macules, plaques, or nodules and occasionally as chronic edema or cellulitis. 1,4 Diagnosis is often delayed by the benign appearance of the tumor and its variable presentation : it is commonly mistaken for a bruise, hemangioma, or focal bacterial or fungal infection. Prognosis for patients with angiosarcoma of the face and scalp is poor, with a 5-year survival rate of approximately 12% to 27%. 2,3,5,6

Mucoepidermoid carcinoma involving the lacrimal sac.

Mucoepidermoid carcinoma of the lacrimal sac was diagnosed in a 62-year-old woman who presented with epiphora and a fixed painless mass in the area of the lacrimal sac. Histopathologic findings included nests and islands of neoplastic cells in a fibrotic stroma. The tumor nests contained both glandular spaces and solid epithelial areas. Treatment entailed dacryocystectomy with silastic intubation and subsequent medial maxillectomy and ethmoidectomy. The patient was tumor free on 1-year follow-up. Clinical features, histopathological findings, prognosis, and management of this rare tumor are reviewed in this article.

Repair of the Superior Sulcus Deformity Using Autogenous Costal Cartilage

Superior sulcus deformity is a late sequela of surgical anophthalmos. Many methods have been proposed to treat this difficult problem. A technique using autogenous costal cartilage that has resulted in satisfactory repair is presented. In addition to standard photographs and exophthalmometry measurements to follow these patients, a specific device to accurately measure orbital volume gain after operation was fashioned.

Keratinous cyst of the palpebral conjunctiva.

A whitish-opalescent, mildly elevated superior tarsal conjunctival lesion measuring 3.0 mm in diameter caused a refractory corneal abrasion in a 54-year-old man. Complete local excision without entering the tarsus produced relief of symptoms. There has been no recurrence during 9 months of follow-up. Histopathologically, a unique keratinous cyst was delimited mostly by basaloid cells resembling the matrical cells in pilomatrixoma. There were no keratohyalin granules in the lining cells, which focally transformed in ghost cells. These histopathologic features are characteristic of trichilemmal keratinization, a heretofore undescribed metaplasia of the conjunctival epithelium.

Correction of Facial Contour Deformities with Prefabricated Sculptured Implants

Close collaboration between the ophthalmologist and ocularist is essential to achieve the best results in the correction of facial contour deformities with prefabricated, sculptured implants. We used previously described techniques to make such implants with RTV-382 silicone and methyl methacrylate resin to correct facial defects. One patient with bony defects of the forehead and superior orbital rim, and another patient with a superior sulcus deformity illustrate the value of these procedures.