George H. Garcia

Criteria for nonsurgical management of subperiosteal abscess of the orbit: analysis of outcomes 1988-1998.

PURPOSE On the basis of bacteriologic studies, we have recommended expectant observation with intravenous antibiotics for subperiosteal abscess (SPA) of the orbit in patients less than 9 years of age, given the absence of eight other specific surgical criteria. We attempted to test these recommendations with a prospective study. STUDY DESIGN Prospective noncomparative case series. PARTICIPANTS Forty patients younger than 9 years of age treated for orbital SPAs at the Childrens Hospital of Wisconsin from 1988 to 1998. METHODS Specific management criteria were applied to a cohort of 37 orbital SPA patients. Three other orbital SPA patients under the age of 9, either ineligible for medical therapy or treated outside our guidelines, were also studied. Clinical data for all patients were reviewed and analyzed. MAIN OUTCOME MEASURES Clinical resolution of the abscess, as evidenced by normal visual acuity, pupillary examination, motility, and globe position on the affected side. RESULTS Eight patients met criteria for surgical treatment and underwent prompt drainage. Of the 29 patients for whom initial nonsurgical management was recommended, 27 (93.1%) SPAs cleared with expectant observation on intravenous antibiotics, and 2 patients defaulted to surgical intervention. All cases had successful clinical outcomes. CONCLUSIONS In patients less than 9 years of age, orbital SPAs are likely to resolve without surgery, provided certain surgical criteria are absent.

Correlation of preoperative computed tomography and postoperative ocular motility in orbital blowout fractures.

Purpose To determine a relationship between preoperative soft tissue disruption and postoperative ocular motility in orbital blowout fractures. Methods This retrospective cohort study reviewed 30 patients who met all criteria: retrievable coronal computed tomography (CT) scans; internal fractures of the orbital floor, with or without medial wall extension; preoperative diplopia; repair by a single surgeon; complete release of entrapped tissues; and postoperative binocular visual fields (BVFs). Motility outcomes were quantified by one group of the authors, who measured the vertical fusion within BVFs. Other authors analyzed CT scans, designating each fracture as either A or B, based on lesser or greater soft tissue distortion relative to the configuration of bone fragments. The interval between trauma and surgery was also determined. Results Among the 15 patients with a postoperative motility outcome poorer than the median (86° or less), four (27%) had A fractures; 11 (73%) had B fractures. Among the 15 patients with an outcome better than the median (88° or more), 10 (67%) had A fractures; five (33%) had B fractures. Differences were more defined away from the median. Among five patients with B fractures and better than the median result, three (60%) had surgical repair during the first week after injury. Among the 11 patients with B fractures and less than the median result, one (9%) had repair during the first week. Conclusions Postoperative motility is influenced by soft tissue–bone fragment relationships. Whether the outcome can be altered by earlier surgery in selected cases will be determined by prospective studies.

Advancement flaps for large defects of the eyebrow, glabella, forehead, and temple.

Purpose To describe a system for reconstruction of large defects of the eyebrow, glabella, forehead, and temple. The system maximizes the use of direct approximation and advancement flaps before resorting to less aesthetic techniques. Methods This was a retrospective cohort study drawn from approximately 70 patients with post-Mohs defects of the eyebrow, glabella, forehead, and temple. Surgical intervention involved the graded application of direct approximation, horizontally oriented advancement flaps, rotational flaps, and free skin grafts. The selection of individual and combined techniques was based on defect area and depth, elasticity of adjacent tissues, and relations of the defect to the neighboring eyebrows and hairlines. Results Reconstructive techniques applied to defects of the eyebrow, glabella, forehead, and temple can be arranged in an incremental scale that provides progressively more tissue but at an escalating aesthetic cost. The usual defect size limits for direct approximation and advancement flaps can be expanded. Conclusions To avoid the limitations of large rotational flaps and skin grafts in this region, maximal use of direct approximation and advancement flaps is recommended.

Acute Dacryocystitis as a Presenting Sign of Pediatric Leukemia

PURPOSE To report acute dacryocystitis with preseptal cellulitis as the presenting sign of leukemia in a child. METHODS Case report and literature review. RESULTS During the initial evaluation of a 17-month-old child with epiphora, left lower eyelid swelling, and a tender left medial canthal mass, a complete blood cell count demonstrated pancytopenia. Bone marrow biopsy disclosed replacement of normal cellular architecture with a dense infiltrate of leukocyte blast forms. DNA analysis disclosed a translocation between chromosome 10 and 11, consistent with the diagnosis of nonlymphocytic leukemia. Although the adjacent lower eyelid cellulitis responded to intravenous antibiotics, lacrimal sac distention decreased only after chemotherapy was initiated. CONCLUSIONS Dacryocystitis with preseptal cellulitis can be a presenting sign of leukemia. This blood malignancy should be considered in patients whose leukocyte counts do not correlate with their clinical presentation.

Qualitative perfusion imaging of the human optic nerve.

Purpose Standard methods for the evaluation of human optic nerve perfusion provide limited information. In this pilot study, the authors investigated the feasibility of qualitative perfusion imaging, a recently developed neuroradiologic technique, as a method of assessing human intraorbital optic nerve blood flow. Methods Qualitative perfusion imaging (based on magnetic resonance fast spin-echo sequences) was used to study the optic nerves of 7 healthy volunteers and 5 patients with known optic nerve disease. Data regarding both study subject background and alteration in optic nerve signal intensity were statistically analyzed. Results Control group subjects were significantly younger than study group subjects. No significant differences in optic nerve signal patterns were found within the control group. Comparison of patients with optic neuropathy against the normal composite revealed substantial differences in enhancement characteristics. Conclusions Qualitative perfusion imaging of the human optic nerve is feasible and may serve as the basis for more advanced neuroradiologic studies of optic nerve blood flow abnormalities.

Periocular deep cutaneous basal cell carcinoma.

PURPOSE The distinction between benign and malignant cutaneous periocular lesions can be difficult, as the clinical history and appearance are often quite similar. When present, typical cutaneous changes are often helpful in distinguishing between benign and malignant neoplasms. However, when tumors lack characteristic epidermal change, histopathologic examination may be necessary to confirm the diagnosis. The authors present their experience in the evaluation and management of two patients with periocular basal cell carcinoma who were initially diagnosed as having benign cysts. METHODS The case records for two patients with periocular basal cell carcinoma were reviewed. Preoperative and postoperative photographs were available for comparison in one case. For each patient, the medical history, clinical presentation, histology, and surgical outcome were reviewed. RESULTS In each case, the periocular mass was initially diagnosed as a benign process. Histopathologic examination following excisional biopsy established the diagnosis of basal cell carcinoma in both patients. Following biopsy, residual tumor was removed by the Mohs micrographic technique. There were no surgical complications and no tumor recurrences during follow-up of one year and eight years. CONCLUSIONS Periocular basal cell carcinoma may mimic benign cystic lesions of the central face. Incorrect diagnosis may result in delayed or inappropriate therapy, or failure to submit seemingly benign lesions for histopathologic examination. Definitive treatment requires complete excision with histologic margin control.