Jan W. Kronish

Eyelid Necrosis and Periorbital Necrotizing Fasciitis: Report of a Case and Review of the Literature

Necrotizing fasciitis is an uncommon and severe soft tissue infection characterized by cutaneous gangrene, suppurative fasciitis, and vascular thrombosis. The disease is usually preceded by trauma in patients that have systemic problems, most commonly diabetes and alcoholism. Streptococcus pyogenes and Staphylococcus aureus are the most frequent bacterial etiologies; however, combinations of numerous facultative and anaerobic organisms have also been isolated. Involvement of the face and periocular region is rare. A case is presented here, as well as a review of the clinical features of 15 other patients previously described, in whom eyelid necrosis due to periorbital necrotizing fasciitis developed. Early surgical debridement and drainage of necrotic tissues and appropriate parenteral antibiotics are the mainstay of therapy. The mortality rate in patients with periorbital spread was 12.5%, with the prognosis known to be adversely affected by delay in diagnosis and treatment and/or extension of infection from the face to the neck. Reconstruction of the eyelids with skin grafts was necessary in most cases to avoid such complications as cicatricial lid retraction, lid malpositions, and lagophthalmos.

Multifocal Static Creamy Choroidal Infiltrates: An Early Sign of Lymphoid Neoplasia

Three patients, each more than 60 years of age at initial presentation, had early stage lymphoid infiltrates (formerly called reactive lymphoid hyperplasia) of the choroid and contiguous extraocular tissues. There were multifocal, confluent, and nonconfluent creamy patches in the choroid. These lesions changed very little over periods of observation ranging from 1 to 4 years and failed to produce ophthalmoscopically visible disturbances of the retinal pigment epithelium (RPE). Fluorescein angiography demonstrated dye collection within the lesions without leakage into the subretinal or subpigment epithelial spaces. Both ultrasonography and computed tomography (CT) showed thickening of the choroid with either anterior or posterior episcleral extensions of lymphoid tissue. Pathologic evaluation of biopsy specimens of extraocular portions of the lesions showed low-grade tumors that were diffuse infiltrates of mature lymphocytes, which exhibited lymphoplasmacytoid features, Dutcher bodies, or small residual germinal centers (so-called borderline lesions). Two patients had uniocular localized disease, whereas the third had bilateral ocular lesions, hypogammaglobulinemia, and another extranodal chest wall lymphoid tumor. Therapy for the localized ocular condition consisted either of oral administration of corticosteroids or low doses of radiotherapy.

Orbital infections in patients with human immunodeficiency virus infection

BACKGROUND Opportunistic infections frequently involve the anterior and posterior segments of the eye but rarely occur in the orbit in patients with human immunodeficiency virus (HIV) infection. The authors managed eight patients with HIV and unilateral orbital infections who presented between July 1988 and March 1995. METHODS Records of the patients were reviewed. A literature review of orbital infections in patients infected with HIV also was conducted. RESULTS There were five men and three women, with a mean age of 33.8 years. The mean CD-4 cell count from five of the eight patients was 18.4 cells/mm3. Invasive aspergillosis was the most common orbital infection occurring in four patients, all of whom had contiguous sinus involvement and intracranial extension. Orbital cellulitis with subperiosteal abscesses secondary to ethmoiditis caused by Propionibacterium acnes and Pseudomonas aeruginosa developed in two patients. Orbital cellulitis and panophthalmitis secondary to Staphylococcus aureus endogenous endophthalmitis developed in one patient, and one patient had presumed syphilitic optic neuritis, orbital periostitis, and necrotizing vasculitis. Five patients had permanent visual loss, including four who had loss of light perception. Four patients died of orbital diseases within 1 year of presentation, and three deaths were attributed to intracranial spread of Aspergillus fumigatus. Other organisms reported in the literature that caused orbital infections in patients with HIV include Rhizopus arrhizus, Toxoplasma gondii, and Pneumocystis carinii. CONCLUSION Opportunistic infections of the orbit from bacterial, fungal, and parasitic organisms should be recognized as a serious complication of systemic HIV infection and are associated with a high ocular morbidity and mortality rate.

The pathophysiology of the anophthalmic socket. Part II. Analysis of orbital fat.

The pathophysiologic mechanisms responsible for the clinical features of the anophthalmic socket are poorly understood. Atrophy of orbital fat has been thought to be a major contributing cause of enophthalmos and the superior sulcus deformities that develop after enucle-ation, but it has never been demonstrated histopathologically or confirmed by scientific analysis. This study was undertaken to investigate the changes that occur in the orbital fat compartment of the anophthalmic socket in an animal model by measuring orbital soft tissue mass and evaluating adipocyte cell size. Instead of reduction in the tissue mass, a statistically significant greater weight of the fat and connective tissue compartment was found in the anophthalmic orbit by nearly 13% compared to the control orbit in the animals in the long-term group. No significant change in the mean maximal diameter of adipocytes developed 7 months after enucleation. These analyses do not support the concept that orbital fat atrophy or a reduction of metabolic activity occurs in the anophthalmic socket in this animal model. From these results and our previous findings that the circulation dynamics and blood flow to orbital tissues do not change after enucleation, we propose that the pathophysiologic basis of the problems associated with anophthalmos is a disturbance in the spatial architecture and interrelationships of the multiple tissue components of the orbit, not a change in the orbital blood flow or development of fat atrophy.

Malignant granular cell tumor metastatic to the orbit

OBJECTIVE Malignant granular cell tumor is a rare type of soft tissue sarcoma. To our knowledge, ocular (eyelid) involvement has been described in only two cases. Herein, we report the clinicopathologic features of an unusual case of malignant granular cell tumor metastatic to the orbit. DESIGN Observational case report. METHODS Retrospective review of the medical record and the histopathologic and electron microscopic findings and review of the literature. RESULTS A 72-year-old man with biopsy-proven granular cell tumor in the cervical region was initially seen with proptosis and motility disturbance. A magnetic resonance imaging scan showed a large intraconal mass, and biopsy of the orbital mass revealed granular cell tumor. Histopathologic examination of the primary neck tumor and the orbital mass revealed increased nuclear atypia and pleomorphism in the consecutive lesions. The morphologic impression of granular cell tumor was also supported by the immunohistochemical demonstration of S-100 protein expression and ultrastructural findings typical of granular cell tumor. Six months after the orbital involvement, systemic workup revealed multiple apparent bony and lung metastases. CONCLUSIONS We report the first malignant granular cell tumor metastatic to the orbit and suggest the inclusion of this tumor in the differential diagnosis of metastatic orbital lesions.

The pathophysiology of the anophthalmic socket. Part I. Analysis of orbital blood flow.

A wide variety of complications of the anophthalmic socket develop in patients after enucleation. including enophthalmos, superior sulcus deformities, eyelid malpositions, implant migration and extrusion, poor prosthetic motility, and socket contraction. Changes in the orbital blood flow and metabolic activity of the socket tissues and atrophy of the orbital fat occurring after enucleation have been suggested as two theoretical mechanisms that result in the development of these clinical conditions. Lack of scientific evidence and a limited understanding of the pathophysiologic basis of the features of anophthalmos led us to evaluate the validity of these proposed mechanisms in an animal model. Selected parameters of the normal orbits were compared with the contralateral anophthalmic orbits at different time intervals after surgery. Orbital blood flow was studied with selective ophthalmic artery angiography and radioactive microsphere techniques. Ophthalmic arteriography demonstrated symmetric caliber and filling characteristics of the major orbital vessels of the control and experimental orbits, although their topographic course was slightly more tortuous in the anophthalmic socket. Results of radioactive microsphere analysis of capillary blood flow per weight of the different orbital tissue compartments of the animals in the long-term group showed no significant difference between the normal and anophthalmic sockets. These findings provide evidence that the circulation dynamics and blood flow to orbital tissues do not change after enucleation surgery.

Necrotizing Keratitis Caused by Capnocytophaga ochracea

We studied three cases of Capnocytophaga keratitis that demonstrated stromal necrosis and a ring infiltrate. In all cases, the keratitis occurred in a previously diseased or traumatized cornea. One patient was treated with chronic antiamoebic therapy for presumed Acanthamoeba keratitis. Two cases resulted in corneal perforation. Laboratory isolation was difficult because of slow, fastidious growth. Capnocytophaga is not uniformly sensitive to commonly used topical antibiotics such as the cephalosporins and aminoglycosides, but may respond to treatment with topical clindamycin.

Early Revision in the Office for Adults After Unsatisfactory Blepharoptosis Correction

The most common complications of levator palpebrae superioris muscle blepharoptosis repair are undercorrection, overcorrection, and abnormalities of the eyelid contour. Previously described nonsurgical as well as surgical methods delay the repair of such complications and introduce the same confounding factors that can affect judgment of the eyelid level as during the initial surgical procedure. Twenty-two patients underwent a highly predictable surgical technique to revise unsatisfactory postoperative eyelid positions. Twenty-five of 26 eyelids (96%) had a satisfactory result and only one of 26 (4%) remained undercorrected. The revision is performed three to four days after the initial blepharoptosis correction and involves blunt separation of the wound without local anesthesia. The levator aponeurosis is advanced or recessed and resutured to the tarsus to achieve the proper eyelid height and contour. The advantages of this revision technique are as follows: (1) the procedure can be quickly and easily performed in the office; (2) the anatomic defects are corrected; (3) sharp dissection, bleeding, and edema are avoided; (4) the technique is painless and usually requires no local anesthetic injections; (5) the tone and function of the levator palpebrae superioris muscle, Müllers, and orbicularis oculi muscles remain undisturbed intraoperatively; and (6) early correction is achieved, thereby enhancing patient acceptance.

Temporal Artery Biopsy Technique: A Clinico-Anatomical Approach

A positive temporal artery biopsy is required to conclusively establish the diagnosis of temporal arteritis. The temporal artery biopsy technique we describe is based on the anatomical branching patterns of the superficial temporal artery, the various fascial layers, and the location of the temporal branches of the facial nerve. Special emphasis is placed on avoiding facial nerve trauma during a biopsy of the frontal branch of the superficial temporal artery. Proper surgical technique combined with a working knowledge of the anatomy of the temporalis region enhances the safety of a temporal artery biopsy procedure.

Magnetic resonance imaging of the orbit. Part II. Clinical applications.

&NA; Imaging of the orbit with magnetic resonance imaging (MRI) provides better anatomic detail with T1‐weighted sequences and superior visualization of pathologic conditions with T2‐weighted sequences. Compared with computerized tomography (CT), MRI has the following advantages: lack of ionizing radiation, direct multiplanar imaging, better contrast resolution, lack of bone artifacts, visualization of bone marrow, superior study of certain neurological disorders, and spectroscopy. Compared with CT, MRI has the following disadvantages: prolonged examination, poorer ability to detect orbital calcifications and cortical bone destruction, poorer spatial resolution, fewer suitable patients, certain image artifacts, high cost of MRI units, and higher cost of MRI examinations.