James C. Orcutt

Factors affecting visual loss in benign intracranial hypertension

Visual function and optic disc appearances were studied in 68 patients conforming to established criteria of benign intracranial hypertension (BIH). The clinical, radiological, and laboratory findings of those patients whose visual field or acuity deteriorated were compared with those who did not deteriorate over an average follow-up of 4.1 years. Definite loss of visual function occurred in 49% of eyes and was severe in 6%. Patients with high grade or atrophic papilledema, or peripapillary subretinal hemorrhage, were significantly more likely to have had deterioration of visual function. Transient obscurations of vision and the presence of optico-ciliary shunts were associated with severe visual loss. Anemia, older age, and high myopia were other risk factors for visual loss. Chronic papilledema may cause progressive visual loss and, for this reason, BIH is not a benign condition; fundal changes and visual function should be carefully monitored.

Eye and visual function in traumatic brain injury

Combat blast is an important cause of traumatic brain injury (TBI) in the Department of Veterans Affairs polytrauma population, whereas common causes of TBI in the civilian sector include motor vehicle accidents and falls. Known visual consequences of civilian TBI include compromised visual acuity, visual fields, and oculomotor function. The visual consequences of TBI related to blast remain largely unknown. Blast injury may include open globe (eye) injury, which is usually detected and managed early in the rehabilitation journey. The incidence, locations, and types of ocular damage in eyes without open globe injury after exposure to powerful blast have not been systematically studied. Initial reports and preliminary data suggest that binocular function, visual fields, and other aspects of visual function may be impaired after blast-related TBI, despite relatively normal visual acuity. Damage to the ocular tissues may occur from blunt trauma without rupture or penetration (closed globe injury). Possible areas for research are development of common taxonomy and assessment tools across services, surgical management, and outcomes for blast-related eye injury; the incidence, locations, and natural history of closed globe injury; binocular and visual function impairment; quality of life in affected service members; pharmacological and visual therapies; and practice patterns for screening, management, and rehabilitation.

Treatment of idiopathic inflammatory orbital pseudotumours by radiotherapy

Radiotherapy offers an alternative to steroid therapy for idiopathic inflammatory orbital pseudotumours. Twenty-four orbits were treated with radiotherapy, of which 75% responded adequately. There were no significant complications and no recurrences during the average follow-up time of 22.3 months (1-50 months). Biopsy, CT scanning, and steroid response of orbital pseudotumours can be helpful in predicting the response to radiotherapy. An adequate response to radiotherapy can be predicted if lymphocytes with germinal centres are present in biopsy specimens. Polymorphonuclear leucocytes and eosinophils suggest a poor response to radiotherapy. Small, discrete, inflammatory masses respond better than large diffuse masses. Pseudotumours initially responding to steroids were likely to respond to radiotherapy.

Gaze-evoked amaurosis

Gaze-evoked amaurosis is a transient monocular loss of vision occurring in a particular direction of eccentric gaze. Six cases are reported with a mean follow-up of 5 years; three with optic nerve sheath meningiomas and three with orbital cavernous hemangiomas. Five of the six patients have had no visual deterioration during follow-up. Bilateral optic nerve sheath meningiomas led to visual deterioration in both eyes of one patient, but gaze-evoked amaurosis was present in only one eye. The symptom of gaze-evoked amaurosis, while alarming, is not predictive of permanent visual loss. Possible mechanisms for gaze-evoked amaurosis include inhibition of axonal impulses or transient optic nerve ischemia.

Endoscopic repair of failed dacryocystorhinostomy

Primary dacryocystorhinostomy (DCR) failure is commonly due to scarring at the rhinostomy site. Nasolacrimal duct obstruction due to scarring may also occur in patients who have had their lacrimal bone removed during maxillary sinus surgery. Five patients following DCR and 3 patients after sinus surgery, all with constant epiphora, underwent endoscopic reconstruction of their lacrimal drainage system. Preoperatively, patency of the bony ostium was determined either by computed tomographic (CT) scan or dacryocystography. Endoscopically, the lacrimal drainage system was reopened then intubated with a silastic stent. Any scar tissue was visualized endoscopically and resected. Seven of the 8 patients have been followed from 3 to 24 months after stent removal, and all have had relief of their epiphora. Endoscopic repair is a useful adjunct in the management of patients with DCR failure or patients with epiphora after removal of the lacrimal bone during sinus surgery. This brief procedure can be performed under local anesthesia, does not require a skin incision, and allows the evaluation and correction of intranasal pathology.

Melanoma Metastatic to the Orbit

Cutaneous malignant melanoma often metastasizes to the lung, bone, liver, subcutaneous tissue, and lymph nodes. Six cases of malignant melanoma metastatic to the orbit are presented, five from cutaneous melanomas and one from a contralateral choroidal melanoma. Melanoma rarely metastasizes to the orbit, but when orbital involvement occurs, widespread metastases are already present. Twenty-two cases were reviewed from the literature; 13 of 14 patients, with sufficient follow-up data, had widespread metastases when they presented with orbital disease. Extraocular muscles appear to be a favored site of metastases. The mean time from orbital presentation to death was 4 months. Orbital metastases from a distant melanoma is, therefore, part of a widespread metastatic process. Treatment should be directed toward palliation.

Asymptomatic orbital cavernous hemangiomas

Computed tomographic (CT) scanning and magnetic resonance imaging (MRI) are commonly performed to evaluate neurologic symptoms. Rarely are asymptomatic orbital tumors discovered, creating uncertainty about their management. Eleven patients are presented who were referred for asymptomatic orbital tumors discovered on either CT scanning or MRI performed for unrelated symptoms of headache, vertigo, peripheral numbness, seizures, stroke, or hallucinations. The asymptomatic orbital tumors were diagnosed clinically and radiologically as cavernous hemangiomas. All the patients were followed clinically and neuroradiologically for an average of 37 months (range, 8 to 120 months). None of the tumors enlarged during this time. The authors conclude that patients who have asymptomatic cavernous hemangiomas, discovered by coincidence during neuroimaging, that bear no relation to the indication for obtaining the CT scan or MRI, can be safely followed by observation as an alternative to surgical excision.

Full-thickness grafting of acute eyelid burns should not be considered taboo.

Split-thickness skin grafts are commonly used for the treatment of acute eyelid burns; in fact, this is dogma for the upper lid. Ectropion, corneal exposure, and repeated grafting are common sequelae, almost the rule. It was hypothesized that for acute eyelid burns, the use of full-thickness skin grafts, which contract less than split-thickness skin grafts, would result in a lower incidence of ectropion with less corneal exposure and fewer recurrences. The records of all patients (n = 18) who underwent primary skin grafting of acutely burned eyelids (n = 50) between 1985 and 1995 were analyzed retrospectively. There were 10 patients who received full-thickness skin grafts (12 upper lids, 8 lower lids) and 8 patients who received split-thickness skin grafts (15 upper lids, 15 lower lids). Three of 10 patients (30 percent) who received full-thickness skin grafts and 7 of 8 patients (88 percent) who received split-thickness skin grafts developed ectropion and required reconstruction of the lids (p = 0.02). No articles were found substantiating the concept that only split-thickness grafts be used for acute eyelid burns. The treatment of acute eyelid burns with full-thickness rather than split-thickness skin grafts results in less ectropion and fewer reconstructive procedures. It should no longer be considered taboo and should be carried out whenever possible and appropriate.

Conjunctival cysts of the orbit

OBJECTIVE This study reviews functionally and anatomically disruptive features of simple conjunctival orbital cysts. DESIGN A case series review from four oculoplastic practices over 6 years. PARTICIPANTS Eleven patients with simple conjunctival cysts of the orbit were identified. INTERVENTION All cysts were excised and evaluated histopathologically. MAIN OUTCOME MEASURES Assessment was made of the length of time from inciting event to presentation, preoperative and postoperative refractive state and ocular motility, the presence or absence of discomfort, and radiographic or clinical evidence of bone remodeling. RESULTS Six of 11 cysts were presumed to be primary, unrelated to antecedent surgery or trauma. Four of 11 cysts were associated with pain or tenderness, 5 cysts induced ocular motility disturbance, 6 cysts caused observable globe distortion or refractive error change, and 6 cysts remodeled bone. CONCLUSIONS Simple conjunctival cysts of the orbit, traditionally regarded as low-pressure lesions with minimal structural impact, may induce considerable anatomic and functional disruption.

Histiocytoid variant of eccrine sweat gland carcinoma of the eyelid and orbit: Report of five cases

OBJECTIVE To study the clinicopathologic features of the histiocytoid variant of adenocarcinoma of the eccrine sweat gland of the eye and orbit. DESIGN Retrospective case series. PARTICIPANTS Five patients undergoing orbital and eyelid biopsy as a diagnostic procedure. METHODS The authors examined the clinical histories and pathologic findings of five patients with eccrine adenocarcinoma of the eyelid with orbital invasion. MAIN OUTCOME MEASURES Clinical and histopathologic examinations, including routine histopathology, immunohistochemistry, and electron microscopy studies. RESULTS The tumors presented as insidious, diffusely infiltrative, firm cutaneous masses in the periocular area that later infiltrated the orbit. Histopathologic examination revealed that the tumors infiltrated the dermis and were composed of cells with a histiocytic to signet ring appearance. Tumor cells exhibited intracellular mucin production. Immunohistochemical stains were positive in tumor cells for low and high molecular weight cytokeratins, carcinoembryonic antigen, and epithelial membrane antigen. Electron microscopic examination showed lumen formation and intracytoplasmic mucin in tumor cells. CONCLUSIONS The histiocytoid variant of adenocarcinoma of the eccrine sweat gland of the eyelid may present as an insidious tumor and diffusely invade the orbit. These cases may be confused with metastatic adenocarcinoma.