James R. Boynton

Proptosis after retrobulbar corticosteroid injections

PURPOSE This report describes the clinical, radiographic, and histopathologic findings in patients with proptosis secondary to lipomatosis after retrobulbar corticosteroid injection. DESIGN Retrospective, noncomparative, interventional case series and review of the literature. METHODS Five patients who developed symptomatic unilateral proptosis after steroid injection were studied and the literature was reviewed. RESULTS No previous description was found in the literature. All five cases were studied with computed tomography, and two cases were confirmed with histopathology. No fibrosis or granulomatous inflammation was identified. CONCLUSIONS Orbital lipomatosis is a potential complication of retrobulbar steroid injections. Symptomatic relief can be provided by a transconjunctival approach to the lower lid fat compartment.

Juvenile ossifying fibroma of the orbit

Juvenile ossifying fibroma is an osseous tumor encased in a sclerotic shell. We report findings of juvenile ossifying fibroma in the orbit of a six-year-old boy. The bony aspects of this tumor may be suspected on physical examination. Magnetic resonance imaging was not helpful in the diagnosis of this fibroma. In fact, the technology was misleading because it did not define clearly the bony aspects of the tumor. In this case, the less costly computerized tomography revealed the bony encasement of the tumor and best defined the borders. With the trend in health care of cost containment, it may be that computerized tomography is the appropriate primary imaging study for some suspected orbital tumors based on thorough clinical examination.

Atypical fibroxanthoma of the eyelid

Atypical fibroxanthomas are tumors that arise in the skin, show strikingly atypical cytologic features, but usually follow a benign clinical course. The authors present a case of atypical fibroxanthoma involving the eyelid. Although early reports noted a favorable prognosis, these tumors can recur aggressively and metastasize. Therefore, complete excision is recommended for atypical fibroxanthomas around the eye.

Periocular malignant fibrous histiocytoma.

We present a case of periocular cutaneous malignant fibrohistiocytoma that invaded the orbit. Complete excision is recommended for atypical fibrohistiocytic tumors around the eye. Examination of specimen margins by frozen section should be undertaken with caution. It is recommended that frozen section evaluation be performed by a pathologist familiar with spindle cell neoplasm to ensure complete removal of this tumor.

The significance of positive margins (known and unknown) at the conclusion of Mohs surgery in the orbital region

Summary: The Mohs fresh tissue technique has provided a high rate of cure in cases of malignant tumors in the orbital region. However, in some patients, tumor may persist after Mohs surgery if margins are falsely negative or if the Mohs surgeon elects to terminate the procedure with known positive margins. We report six patients who had residual tumor present in the periorbital region after Mohs surgery. These patients have a serious prognosis associated with subsequent morbidity. Accurate communication between the Mohs surgeon and subsequent treating surgeons, combined with aggressive tumor management, may help to minimize morbidity and improve mortality.

Eye Banking: Techniques for Eye Preservation in Selected Neoplasms Encroaching on the Globe

Removal of the globe and associated structures has been advocated for tumors Invading the periorbital bone and periosteum, orbital fat, or extraocular muscles. In some patients with cancerous tumors encroaching on the globe, however, it may be possible to remove the tumor and save the eye. Tenons fascia is a firm fibrous sheath surrounding the entire globe except the cornea. If the neoplasm spreads along fascial planes rather than through them, and If this layer remains free of tumor Involvement, preservation of the globe can be considered. Oculoplastic reconstructive techniques may limit exposure and diplopia, allowing the eye to be “banked” in vivo, and saved as a spare for the future. Six patients with malignant tumors encroaching on the globe have had definitive surgical extirpation with preservation of the eye. Three patients have had the globe uncovered successfully. Five of six patients remain disease-free, with followup from 6 months to 6 years. No globes have been removed. These techniques appear to be therapeutically sound, preserve function and appearance, and Improve patient morale. The indications and limitations of this approach to certain cases of periorbital cancer are discussed.

Large Periocular Keratoacanthoma: The Case for Definitive Treatment

Keratoacanthoma can usually be distinguished from squamous cell carcinoma. However, some tumors share certain characteristics of both lesions. There is a large group of actinic keratoacanthomas cytologically identical to squamous cell carcinomas. In locations other than the ocular adnexae, conservative therapy is often recommended for keratoacanthomas since these lesions tend to regress spontaneously. Two patients with large periocular keratoacanthomas illustrate some of the diagnostic and therapeutic dilemmas related to rapidly growing potentially malignant lesions about the eye. Extensive tissue destruction and possible recurrence following excision favor definitive surgical therapy in these cases.

Distention of the Lacrimal Sac in Neonates

We present seven cases of neonatal lacrimal sac distention, ranging from sterile dacryocystocele, subacute dacryocystitis, and acute dacryocystitis. Three patients were cured by probing, one by digital pressure decompression, and two by silicone tube intubation.

Complications of Eyelid Reconstruction Using a Semicircular Flap

Complications of the semicircular flap technique of eyelid reconstruction include lateral canthal webbing, ectropion, lid notching, symblepharon, and tissue fullness of the lateral lid. These difficulties occur infrequently and rarely cause significant problems. Attention to surgical details, however, can minimize unfavorable results. It should be emphasized that the semicircular flap remains a superb technique for reconstruction of defects involving up to 80% of the lower eyelid.