Garry Davis

Mechanical endonasal dacryocystorhinostomy versus external dacryocystorhinostomy.

Purpose To compare the success rates of a new mechanical endonasal dacryocystorhinostomy (MENDCR) technique and the conventional external dacryocystorhinostomy technique (Ext-DCR). Methods A prospective, nonrandomized interventional comparative case series of 31 consecutive MENDCRs and 24 Ext-DCRs performed from January 1999 to December 2000. Patients with anatomic nasolacrimal duct obstruction were included in the study; previous lacrimal surgery and functional nasolacrimal and canalicular obstruction were exclusion criteria. Two surgeons performed the MENDCRs, using a standardized operative technique, which involved creation of a large bony ostium and mucosal flaps between the lacrimal sac mucosa and nasal mucosa. One surgeon performed all Ext-DCRs. Results Twenty-seven patients (8 men, 19 women) underwent 31 MENDCRs. The average age of the patients was 62.9 years (range, 15 to 86 years; SD, 19.1 years). In 11 cases (35.4%), a septoplasty was required at the time of surgery, and in 6 cases (19%), further endoscopic sinus surgery was performed. In the Ext-DCR group, 23 patients (7 men, 16 women) underwent 24 DCRs. The average age was 59.6 years (range, 22 to 86 years; SD, 18.5 years). No other nasal procedures were performed at the time of surgery in this group. The average follow-up time was 13 months for the MENDCR group and 12.4 months for the Ext-DCR group. Success was defined as relief of symptoms and by anatomic patency, which was assessed by history, fluorescein flow on nasal endoscopy, and lacrimal syringing. In the MENDCR group, surgery was successful in 29 of 31 DCRs (93.5%); 1 of 2 failed cases was anatomically patent but symptomatic, yielding an anatomic patency rate of 96.8%. In the Ext-DCR group, the success rate was 95.8% (23/24 DCRs); the failed case was anatomically patent but symptomatic, giving an anatomic patency rate of 100%. The differences in overall success and anatomic patency were not statistically significant (P = 0.6 and P = 0.56, 1-tailed Fisher exact test). Conclusions The success rate of MENDCR (93.5%) compares favorably with that of standard external DCR (95.8% in this study). MENDCR relies on the creation of a large ostium and mucosal flap apposition. A larger, randomized prospective trial is needed to fully assess the efficacy of this new technique.

Revision dacryocystorhinostomy: a comparison of endoscopic and external techniques.

Background Success rates for revision dacryocystorhinostomy (DCR) are lower than primary DCR. Scarring of the sac may limit the ability of the surgeon to achieve good nasal and lacrimal mucosa apposition. This study evaluates the comparative success rates of the external and endoscopic techniques for revision DCR. Methods Seventeen consecutive revision endoscopic DCRs (average age, 60.9 years) and 13 revision external DCRs (average age, 65.1years) performed from January 1999 to December 2000 performed by separate surgeons were entered into the study. Patients with functional nasolacrimal and canalicular obstruction were excluded. The average follow-up was 11.1 months for the endoscopic DCR group and 10 months for the external DCR group. Results A successful DCR required complete relief of symptoms and an endoscopically determined anatomic patency of the nasolacrimal system. Revision endoscopic DCR surgery was successful in 76.5% of cases (13 of 17 cases) and external DCR surgery was successful in 84.6% (11 of 13 cases). This difference was not statistically significant. (p = 0.64, Fisher exact test with a two-tailed probability). Conclusion Revision endoscopic DCR has a success rate of 76.5%, which compares favorably with that of the revision external DCR (84.6%).

Cerebrospinal Fluid Leaks in Orbital and Lacrimal Surgery

Cerebrospinal fluid leakage is an uncommon but significant complication of orbital and rarely lacrimal surgery which may have serious consequences including death. In a retrospective review of four orbital units, we report an incidence of cerebrospinal fluid leak (diagnosed intraoperatively) during exenteration, orbital decompression, and dacryocystorhinostomy of 1/154 (0.6%), 4/397 (1%), and 0/3,504 (0%), respectively. We found two additional cases of cerebrospinal fluid leaks associated with excision of orbital masses involving the orbital roof. In the literature, the incidence of cerebrospinal fluid leaks associated with orbital exenterations and decompressions was 1.6-16.7% and 0-10%, respectively. Cerebrospinal fluid leaks occur very rarely in dacryocystorhinostomies with only a few case reports found in the literature. Preventative measures, diagnosis, and management of this complication are discussed. Knowledge of anatomy and thorough preoperative assessment may predict areas at high risk for encountering cerebrospinal fluid leaks. Proper surgical technique further minimizes the risk for this complication. If a cerebrospinal fluid leak occurs, however, prompt diagnosis and management usually results in uncomplicated recovery.

Intraepithelial sebaceous carcinoma of the eyelid misdiagnosed as Bowen's disease

Background:  Sebaceous carcinoma (SC) is well known for its ability to masquerade clinically and histologically as a variety of periocular conditions resulting in a delayed diagnosis. We present a series of periocular SC cases and discuss the difficulties in histopathological diagnosis when this tumor presents with a Bowenoid pattern of intraepithelial spread.

Delayed complications of silicone implants used in orbital fracture repairs.

Purpose: To report a series of patients who developed late complications secondary to silicone implants used in orbital fracture repairs and review the literature. Design: Retrospective interventional case series. Methods: Analysis of records of patients who developed complications following repair of orbital wall fractures with silicone implants. Results: Over a 5-year period, 4 patients were seen with complications arising from a silicone orbital implant. There were 3 males and 1 female whose ages ranged from 41–73 years. The time interval between initial insertion of implant and development of complications was 1.5, 6, 10, and 20 years. The complications noted were worsening diplopia, recurrent orbital cellulitis, lower lid retraction with restricted upgaze, and orbital abscess. Computed tomographic scans demonstrated the implant in all cases. Histologic examination revealed nonspecific chronic inflammation and fibrosis in all cases and foci of squamous epithelium in one case. Treatment included surgical removal of the implant, resulting in complete resolution or significant improvement in symptoms and signs in all cases. Conclusion: The use of silicone implants is associated with a wide range of complications, which may occur many years following the original surgery. Surgical removal of the implant usually leads to resolution of symptoms. Given the potential of silicone implants to cause delayed complications, their use in orbital fracture repair is not recommended.

Orbital arteriovenous malformations

OBJECTIVE To present the clinical features, management, and outcomes in a series of patients with orbital arteriovenous malformations (AVMs). METHODS Clinical records of patients with orbital AVMs confirmed using angiography were reviewed as a retrospective, noncomparative, interventional case series. RESULTS Eight patients (3 women and 5 men) with unilateral AVMs and a mean age of 39 years (median, 36.5 years; range, 26-70 years) were reviewed. Findings existed for an average of 11.2 years before diagnosis and included periocular mass (7 patients, 88%); periocular edema, pulsation/bruit, proptosis, episcleral congestion, and previous trauma (4 patients each, 50%); elevated intraocular pressure (3 patients, 38%); pain and reduced visual acuity (2 patients each, 25%); and restriction of extraocular movements, and diplopia (1 patient each, 12%). All of the patients except 1 underwent surgical resection, with 3 (38%) receiving preoperative embolization of feeder vessels; all of the patients had initial resolution of manifestations after treatment. CONCLUSIONS Angiography is essential for diagnosis and for planning the management of orbital AVMs. Treatment depends on patient-specific features and includes observation, embolization, and surgical excision or combined preoperative embolization/excision. Given their vascular nature, the main cause of poor management outcomes is perioperative hemorrhage. Outcomes after a multidisciplinary approach are good, with few recurrences reported at follow-up.

Primary orbital intraosseous hemangioma.

Purpose: Primary orbital intraosseous hemangioma represents a rare, histopathologically benign, vascular tumor of the bony orbit. Only 41 cases have been documented in the literature to date. The authors present 4 new cases of the disease and review the relevant literature. Methods: Retrospective, multicenter case note analysis of 4 patients with histopathologically confirmed primary orbital intraosseous hemangioma and a systematic review of the English-language literature. Results: Four new cases of cavernous haemangiomata are presented with varying clinical manifestations, radiologic appearances, and treatments. Literature review (including the present 4 cases) yielded 45 cases in total. Presentation is often in the fourth and fifth decades (42% cases), the frontal bone being most commonly affected, followed by the zygoma, sphenoid, and maxilla. Intracranial extension occurred in 4 cases. Median duration of symptoms before presentation was 12 months (range, 1 month to 15 years) and the most frequent presentation was a painless mass, often on the orbital rim. The radiologic findings are reviewed. Histopathologically, the lesions were cavernous in 80%, capillary in 17%, and mixed in 3%; the capillary subtype seemed to be associated with more aggressive disease. Treatment was mainly by surgical excision and occasionally complicated by significant blood loss; preoperative embolization of lesions may reduce bleeding. Conclusions: Primary orbital intraosseous hemangioma is a rare vascular tumor that typically presents with a mass effect in the orbits of patients in the fourth and fifth decades of life. Preoperatively, it is important to be cognizant of the possible diagnosis as surgery can be complicated by life-threatening hemorrhage.

Lesions mimicking lacrimal gland pleomorphic adenoma.

Aim To report a series of patients with lacrimal gland lesions simulating the clinicoradiological features of lacrimal gland pleomorphic adenoma (LGPA). Methods Multicentre retrospective, interventional case series. Clinical records of all patients with lesions mimicking LGPA seen in five orbital units were reviewed. Results The study included 14 patients (seven men and seven women) with a mean age of 50.9 years. The diagnosis of LGPA was made in all cases by experienced orbital surgeons, based on clinicoradiological features, and lacrimal gland excision was performed. Postoperative histology revealed lymphoma (four patients), chronic dacryoadenitis (three patients), adenoid cystic carcinoma (two patients), Sjogrens syndrome (two patients), cavernous haemangioma (one patient), benign lymphoid hyperplasia (one patient) and granulomatous dacryoadenitis (one patient). Comparison with the total number of histologically confirmed LGPA cases seen during the study period revealed that 22.6% of cases of suspected LGPA were misdiagnosed based on clinicoradiological criteria. Conclusions Many different lesions may mimic the clinicoradiological features of LGPA. The accepted clinicoradiological criteria used for the diagnosis of LGPA have a high false-positive rate, even in experienced hands. Based on this study, the authors believe that fine-needle aspiration biopsy or intraoperative biopsy and frozen section diagnosis may help reduce unnecessary lacrimal gland excision.

Periocular keratoacanthoma: can we always rely on the clinical diagnosis?

Aim: To present a series of patients with a clinical diagnosis of periocular keratoacanthoma and assess the incidence of histologically proven invasive squamous cell carcinoma (SCC). Methods: This retrospective case series included all patients with periocular tumours seen in the authors’ unit between 1996 and 2004, and who were initially diagnosed with keratoacanthoma based on the clinical presentation. Results: Twelve patients (eight males, four females) were clinically diagnosed with keratoacanthoma. The final histological diagnosis revealed two cases (16.7%) of invasive SCC, and 10 cases (83.3%) of keratoacanthoma. The lower lid was most commonly involved in cases of keratoacanthoma (50.0%). Six patients (60.0%) underwent Mohs surgery, and four (40.0%) were treated with excision under frozen section control. There were no cases of recurrence during a mean follow up period of 21 (SD 13) months. Conclusion: Although the clinical presentation of periocular keratoacanthoma is usually characteristic, a significant percentage of patients will prove to have invasive SCC. Complete excision with margin control offers a definitive diagnosis, as well as tissue conservation and a low recurrence rate.

Orbital lipomatous haemangiopericytoma: an unusual variant.

Haemangiopericytoma (HPC) of the orbit is a rare tumour occurring in all age groups and presenting with slowly progressive proptosis, ocular motility impairment and visual loss. Although most are benign tumours that are resectable at diagnosis, one‐third of these tumours demonstrate malignant features and recur locally or metastasize, usually with a fatal outcome. In 1995, a morphologically unique variant, termed lipomatous haemangiopericytoma (L‐HPC), was described. Only one case has been reported previously arising in the orbit. In this paper, a case is reported of L‐HPC occurring in the orbit and consider the prognostic implications of this HPC variant.