Gerald J. Harris

Subperiosteal Abscess of the Orbit: Age as a Factor in the Bacteriology and Response to Treatment

BACKGROUND Earlier studies of subperiosteal abscess secondary to sinusitis showed considerable variation in the clinical course and bacteriology. At one extreme, patients recovered with intravenous antibiotics alone; at the other extreme, complex pathogens persisted despite early surgical drainage and appropriate antibiotics, and visual or intracranial complications occurred. To better direct management of individual patients, this study evaluates the role of patient age in the complexity and responsiveness of subperiosteal abscess. METHODS The records of 37 patients with a computed tomography diagnosis of subperiosteal abscess were reviewed. Initial and follow-up culture results were evaluated in the context of prior treatment of individual patients. Responses to therapy and pathogens were compared among three age groups. RESULTS Among patients younger than 9 years, 83% either cleared without drainage (25%) or had negative cultures at the time of drainage (58%). In the culture-positive cases, single aerobes were found, and anaerobes were not isolated. Patients 9 to 14 years old showed a transition toward more complex infections. Patients 15 years of age or older all had positive cultures after more than 3 days of antibiotics, which were frequently effective in vitro. Polymicrobial infections were the rule, including anaerobes in every case. CONCLUSION Variations in the complexity and responsiveness of subperiosteal abscesses appear to be age-associated. Treatment protocols should consider visual compromise, pain, location of the abscess, which sinuses are involved, intracranial complications, and the age of the patient.

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.

Idiopathic Sclerosing Inflammation of the Orbit: A Distinct Clinicopathologic Entity

BACKGROUND Idiopathic sclerosing inflammation of the orbit is a poorly delineated, fibrosing, immune-mediated entity resulting in significant ocular disability. To characterize this process and propose more specific and effective therapy, clinical and pathologic findings in 16 cases are reviewed. METHODS The clinical records of 16 patients with biopsy-proven disease were retrospectively reviewed to determine demographic and clinical features, radiologic features, course, management, and outcome. These findings were correlated with pathologic features to describe this unique entity. Immunohistologic characteristics were compared with those of a clinically and histopathologically similar process, retroperitoneal fibrosis. RESULTS The study included 11 male and 5 female patients, ranging in age from 8 to 81 years. Disease onset was usually unilateral (14/16) and chronic (11/15), with two distinct anatomic presentations, lacrimal (11/16) and apical (3/16), characterized by infiltration (15/16), mass effect (12/16), and visual loss (3/16). The most common signs and symptoms were dull pain (13/16), proptosis (11/16), mild inflammation (11/16), restricted motility (9/16), swelling (9/16), and diplopia (8/16). Two features, a sparse, chronic inflammatory infiltrate, the immunopathologic characteristics of which suggested a cell-mediated process, and a desmoplastic stroma of early onset, dominated the pathologic picture. Treatment with corticosteroids (11/16), radiotherapy for steroid failures (8/11), and observation alone (3/16) was inadequate, resulting in blindness in 3/16 cases, restricted movement in 10/16, and complete resolution in only 2/16 patients. CONCLUSION Idiopathic sclerosing inflammation of the orbit is a unique clinicopathologic entity, similar to retroperitoneal fibrosis, that is characterized by primary, chronic, and immunologically mediated fibrosis, poor response to corticosteroid treatment or radiotherapy, and frequent visual disability. Early and aggressive immunosuppressive therapy is recommended.

AN ANALYSIS OF THIRTY CASES OF ORBITAL LYMPHANGIOMA : PATHOPHYSIOLOGIC CONSIDERATIONS AND MANAGEMENT RECOMMENDATIONS

Thirty cases of orbital lymphangioma were reviewed. Clinical, imaging, and microscopic findings were integrated to develop a pathophysiologic construct and management guidelines. The basic lesion might be considered an abortive vascular system which arborizes among normal structures. Intrinsic hemorrhage expands portions of the small-caliber network into large blood cysts, prompting clinical recognition. While major hemorrhage led to early surgery in 12 cases, long pretreatment intervals could be analyzed in 17 others. Twelve patients had second hemorrhages of varied magnitude, from 2 weeks to 15 years after initial recognition; five patients did not in an average of 6.8 years. Some blood cysts contracted spontaneously. Among 23 operated cases, 12 patients had major new bleeds from 4 days to 12 years after initial surgery; 11 patients did not in an average of 4.2 years. Poor final visual acuity was associated with multiple surgeries. The authors advocate conservatism in surgical case selection and in operative dissection.

Congenital Dacryocele: A Collaborative Review

Fifty-four cases of congenital dacryocele from several medical centers were reviewed retrospectively. There was strong female preponderance (73%) and unilateral involvement (88%). Lacrimal sac contents could be expressed by local massage through the puncta in 21% of cases. Probing and irrigation were done under general (27.8%) or local (55.6%) anesthesia, while in other cases (16.7%), the cyst resolved before intervention. Recurrence of the dacryocele occurred in 10 patients (22%) after probing. Nasal cysts were visualized in six cases. Marsupialization of nasal cysts was necessary in four cases. In one center, after conservative therapy, 80% of cysts resolved spontaneously and 20% developed dacryocystitis. Surgical intervention is indicated in cases of dacryocystitis, cellulitis, breathing difficulty from large nasal cysts, recurrent dacryocele, and lack of its resolution after a short trial of digital massage.

Bilateral retinal embolization associated with intralesional corticosteroid injection for capillary hemangioma of infancy

A 2-month-old female infant underwent intralesional corticosteroid injection for a capillary hemangioma that was causing amblyopia of the right eye from ptosis, globe displacement, and astigmatism. Forty-eight hours after the injection, the infants parents noted that she was visually inattentive. On examination, she could not fixate or follow with either eye, and an afferent pupillary defect was present in the left eye. Ophthalmoscopy showed scattered areas of intraretinal hemorrhage in the right eye and extensive preretinal and intraretinal hemorrhages in the left eye. Ten months after injection, the hemangioma had greatly regressed, and visual acuity in the right eye was felt to be normal. The left eye had unsteady fixation with a persistent afferent pupillary defect and macular scarring. Retrograde flow of the corticosteroid suspension through the hemangiomas feeder vessels, probably originating from both ophthalmic arteries, is the most likely explanation for this complication.

The silent sinus syndrome: a case series and literature review.

Purpose The purpose of this study is to describe the clinical and pathologic features of a form of chronic maxillary atelectasis referred to as the silent sinus syndrome, which is characterized by progressive enophthalmos secondary to maxillary collapse resulting from maxillary sinus hypoventilation.

Orbital blow-out fractures: surgical timing and technique.

PurposeTo recommend a tailored approach to surgical timing in the repair of orbital blow-out fractures, and to offer suggestions for improved functional and aesthetic surgical outcomes.MethodsTraditional guidelines for surgical timing are reviewed. An evidence-based approach that considers soft-tissue disruption relative to bone-fragment separation is presented. The authors techniques for repair of isolated orbital floor, isolated medial wall, and combined floor–medial wall fractures are presented.ResultsAs demonstrated previously, greater degrees of soft-tissue incarceration or displacement, with presumably greater intrinsic damage and subsequent fibrosis, result in poorer motility outcomes despite complete release of soft tissues. There is a suggestion that earlier intervention for such injuries might improve outcomes. Lower fornix and transcaruncular incisions, careful extrication of incarcerated tissue, and thin alloplastic implants have proven successful in the authors hands.ConclusionsThe degree of soft-tissue displacement relative to bone fragment distraction, as depicted in preoperative computed tomography (CT) scans, should be considered in the timing of surgery. Incisions, soft-tissue handling, and implant material, thickness, and positioning can all affect the functional and aesthetic outcomes.

Idiopathic orbital inflammation: a pathogenetic construct and treatment strategy: The 2005 ASOPRS Foundation Lecture.

Although it is generally recognized when seen, idiopathic orbital inflammation (IOI) can be difficult to define with precision. It can be distinguished from inflammation with an identifiable cause, including bacterial and fungal infection, foreign body reaction, and the response to dermoid cyst leakage. It can be separated from conditions—although equally idiopathic—that have characteristic histopathologic patterns or systemic associations. Examples include Wegener granulomatosis, lupus erythematosus, histiocytoses, xanthogranulomas, sarcoidosis, and Graves disease. There remains a constellation of signs, symptoms, imaging features, and histopathologic findings that is known by several names, including IOI, nonspecific orbital inflammation, and orbital pseudotumor. Despite changes in its meaning, the last term appears to be tenaciously entrenched in the lexicon. When it was coined 75 years ago, pseudotumor subsumed all of the foregoing entities; as they were better characterized, many were moved out of the category, and the term’s scope has gradually contracted. Although that trend will continue, we must manage what is left, preferably in a systematic manner. As clinicians, we get the clear impression that “what is left” is not a uniform or monolithic condition.

Noninfectious Inflammatory Response to Gold Weight Eyelid Implants

Summary We describe three patients with noninfectious inflammatory reactions to gold weight eyelid implants, a complication not previously reported. Eyelid edema and erythema developed gradually in each patient, and maximal inflammation that prompted treatment was present at 12, 3, and 5 weeks, respectively, after surgery in the three patients. Management involved removal of the implant in the first patient, oral corticosteroids followed by replacement of the implant by a platinum weight in the second patient, and a local corticosteroid injection with retention of the implant in the third. Histopathological features included a thick eosinophilic coagulum at the tissue-gold interface and an intense, predominantly lymphocytic infiltrate in the collagenous capsule that surrounded the implants. Gold weight eyelid implants can elicit a gradually progressive inflammatory response. In at least some cases, local corticosteroid injection may suppress the inflammation and permit retention of the implant.