Jason A. Sokol

Orbital compression syndrome in sickle cell disease.

Purpose: To present 3 cases of orbital compression syndrome caused by infarction of the greater wing of the sphenoid in patients with sickle cell disease. Methods: Case report and review of the literature. Results: Three patients with sickle cell disease (2 males aged 22 and 16 years, and a 10-year-old girl) who presented with proptosis, limited ocular motility, and chemosis were found to have an infarction of the marrow space of the greater wing of the sphenoid that produced an orbital subperiosteal hemorrhage and exudate demonstrated on MRI. Two patients suffered compressive optic neuropathy; both patients recovered normal optic nerve function. Orbital edema resolved within 48 hours of receiving 1 g methylprednosolone daily. The third patient had normal optic nerve function and his orbital edema improved with methylprednisolone 250 mg/day and intravenous Kefzol over 3 days. In the literature, there are 27 similar cases; 5 were treated surgically and the remainder were managed medically. Conclusions: Patients with sickle cell disease are at risk for orbital compression syndrome secondary to orbital bone infarction, in the setting of vaso-occlusive crises. This diagnosis should be considered when a patient with sickle cell disease presents with headache, proptosis, decreased motility, and/or optic nerve compromise.

Bilateral Lacrimal Gland Disease: Clinical Features of 97 Cases

OBJECTIVE Bilateral lacrimal gland (LG) disease is a unique presentation that can result from varied causes. We reviewed the diagnoses, clinical features, and outcomes of 97 patients with this entity. DESIGN Case series. PARTICIPANTS Ninety-seven patients with bilateral LG disease. METHODS Retrospective review and statistical analysis using analysis of variance and the Fisher exact test. MAIN OUTCOME MEASURES Patient demographics, clinical features, diagnostic testing, diagnosis, and treatment. RESULTS Patient age ranging from 8 to 84 years (mean, 46 years). The predominant gender was female (77%), and race included black (49%), white (38%), and Hispanic (12%) patients. Diagnoses fell into 4 categories: inflammatory (n = 51; 53%), structural (n = 20; 21%), lymphoproliferative (n = 19; 20%), and uncommon (n = 7; 7%) entities. The most common diagnoses included idiopathic orbital inflammation (IOI; n = 29; 30%), sarcoidosis (n = 19; 20%), prolapsed LG (n = 15; 15%), lymphoma (n = 11; 11%), lymphoid hyperplasia (n = 8; 8%), and dacryops (n = 5; 5%). Inflammatory conditions were more likely in younger patients (P<0.05) and in those with pain (P<0.001) and mechanical blepharoptosis (P<0.01) at presentation, whereas lymphoma was more common in older patients (P<0.001) without active signs of inflammation at presentation. Black patients were more likely to have sarcoidosis (P<0.01). Laboratory results showed high angiotensin converting enzyme level being significantly more likely in patients with sarcoidosis (P<0.05). However, sensitivity was limited to 45%, with 25% of patients diagnosed with IOI also demonstrating positive results. Corticosteroid therapy was the treatment of choice in 38 cases, corresponding to resolution of symptoms in 29% and improvement in an additional 32%. Overall, chronic underlying disease was found in 71% of patients, among whom 26% achieved a disease-free state, whereas 3% succumbed to their underlying disease. CONCLUSIONS The cause of bilateral lacrimal gland disease most commonly was inflammatory, followed by structural and lymphoproliferative. Patient characteristics and clinical presentations were key features distinguishing between competing possibilities. Despite local control with corticosteroids or radiotherapy, underlying disease continued in 71% of patients and led to death in 3%.

CD56 Negative Extranodal NK/T-cell Lymphoma of the Orbit Mimicking Orbital Cellulitis

ABSTRACT Introduction: To report a case of Extranodal NK/T-cell lymphoma of the orbit mimicking orbital cellulitis. Case Description: A 52-year-old healthy male presented to our institution after 3 months of treatment for sinusitis with antibiotics and steroids. The patient was transferred due to the presence of an “orbital abscess” on CT with orbital signs that not responding to antibiotics. Clinical examination was significant for decreased vision in the affected orbit of 20/50, a trace RAPD OS, elevated IOP of 30 OS, proptosis and grossly decreased motility with diplopia, periorbital edema and chemosis. Dilated funded exam was unremarkable. CT imaging demonstrated a left sided pan-sinusitis, a medial “orbital process” with proptosis and erosion of the cribiform plate. The patient was taken for an emergent orbital exploration for histopathologic diagnosis. Intraorbital and sinus biopsy was consistent with extranodal NK/T-cell lymphoma, with extension into the skull base and left orbital space. The patient was started on radiation therapy followed by chemotherapy. Comments: The authors demonstrate how the acute presentation of an aggressive extranodal NK/T-cell lymphoma can present in a similar fashion as orbital cellulitis. Additionally, the case highlights that a unilateral pansinusitis with involvement of the skull base and orbit is likely due an aggressive malignant process in an immune competent patient.

Radiographic evidence of prominent retro and suborbicularis oculi fat in thyroid-associated orbitopathy

ABSTRACT Purpose: To compare the radiological differences in retro-orbicularis oculi fat (ROOF) and suborbiculars oculi fat (SOOF) among patients with thyroid-associated orbitopathy (TAO) and normal subjects using computed tomography (CT).Methods: A retrospective analysis of orbital CTs was performed in 39 consecutive patients, who were imaged between October 2005 and June 2009. Bilateral orbital CTs of 16 patients with a final report significant for thyroid orbitopathy and 23 normal subjects were evaluated. All of the CTs consisted of 0.75 mm thick axial slices with 1.5 mm coronal reconstructions. Using the axial soft tissue windows, the ROOF and SOOF tissues were identified. The maximum ROOF thickness was measured perpendicular to the frontal bone, immediately superior to the supraorbital rim. Similarly, the maximum SOOF thickness was measured perpendicular to the zygomatic bone, immediately inferolateral to the infraorbital rim. The radiologist was blinded to the CT reports while conducting the measurements. Multivariable analysis of the two groups was then performed for comparison.Results: Seventy-eight ROOF and SOOF measurements were obtained from 16 TAO patients with and 23 patients without TAO. The female-to-male ratio was 6:1 in the TAO group and only 3:2 among the normal subjects. The mean axial ROOF thicknesses was 3.8 ± 1.9 for TAO patients and 2.8 ± 1.0 mm in patients without TAO, while the SOOF thickness was 4.4 ± 1.0 and 3.4 ± 1.0 mm in the 2 groups, respectively. To account for bilateral measurements, the mixed model analysis was used. After controlling for age, gender, and ethnicity, the mean TAO ROOF and SOOF thicknesses were 1.0 mm (p = 0.04) and 0.9 mm (p < 0.01) greater than the control group, respectively.Conclusion: Retro-orbicularis oculi fat (ROOF) and suborbicularis oculi fat (SOOF) hypertrophy are two additional radiologic CT measurements that may be valuable in establishing the diagnosis of thyroid-associated orbitopathy.

Transcutaneous medial canthal tendon incision to the medial orbit.

Purpose: The surgical approach to the medial orbit allows superior exposure of the medial orbital wall and nasal bones, extending to the orbital apex, with excellent cosmetic results. Methods: This is a retrospective database study of all patients (N = 98) undergoing a transcutaneous medial canthal tendon incision in practice during 2009. This 1.5- to 2.0-cm incision is made just anterior to, in the same plane as, and shaving the anterior ramus of the medial canthal tendon. After exposing the origin of the anterior ramus of the medial canthal tendon, the periorbita along with the attached medial canthal tendon is elevated, exposing the entire medial orbital wall from the orbital strut to the trochlea. Anterior dissection allows access to the nasal bones to the dorsum of the nasal bridge. The parameters studied in this report were the complication rates (including scarring requiring revision, telecanthus, diplopia related to the technique, and injury to the optic nerve or other orbital structures) and photographic evidence of the final cosmetic result of this approach. Results: During 2009, 173 surgical procedures were performed through the transcutaneous medial canthal tendon incision. The procedures comprised 89 fracture repairs of the nasal or ethmoid complex, 2 naso-orbito-ethmoid fracture repairs, 4 cases of isolated nasal fracture repair, 37 medial wall decompressions for ophthalmic Graves disease, 13 cases of subperiosteal abscess drainage, and 28 dacyrocystorhinostomies using a slightly modified incisional position. The inferior oblique was not cut or released in any of these cases. There were no observed cases of medial canthal webbing, injury to orbital structures, telecanthus, optic neuropathy, or iatrogenically induced diplopia related to the technique. By definition, the authors’ follow-up time is limited to less than 2 years in each case; however, all complications, which the authors have considered for this report, would have been readily observable in this postoperative period. Conclusions: The small incision, transcutaneous medial canthal approach offers excellent and safe exposure of the medial wall, nose, and the orbital apex. The authors differentiate this transcutaneous medial canthal tendon incision from the less cosmetically acceptable, larger and more anterior Lynch incision. This medial canthal tendon incision has, and continues to be, a workhorse in the authors’ approach to the medial orbit and nose while offering unparalleled exposure with an excellent safety and complication profile.

Modified frontalis suspension technique with review of large series.

Purpose: To describe and report results of a modified frontalis suspension technique utilizing direct fixation to tarsus, lash margin rotation, eyelid crease fixation, conservative blepharoplasty, and rhomboidal configuration. Methods: A retrospective chart review of frontalis suspension patients over a 28-year period was performed. Results: Data from 171 eyelids in 93 patients were reviewed. Ages ranged from 1 to 84 years with a median age of 16. The indications for surgery included the following: congenital ptosis in 107 eyelids (62.6%), chronic progressive external ophthalmoplegia in 17 (9.9%), jaw winking ptosis in 14 (8.2%), blepharophimosis in 12 (7.0%), cranial nerve III palsy in 10 (5.8%), traumatic ptosis in 9 (5.3%), and myasthenia in 2 (1.2%). Autogenous fascia lata was utilized in 156 lids (91.3%), while silicone rods or banked fascia was used in 11 (6.4%) and 4 (2.3%) lids, respectively. Average follow up was 11.7 months (range 2 to 108 months). An excellent result was defined as ≤1 mm asymmetry in primary gaze and an eyelid position of 2.5 mm or less below the superior limbus. Eighty-nine of 93 patients (95.7%) achieved excellent results. Six lids in 4 patients (3.5%) were undercorrected. No patients were overcorrected. Only 2 patients with autogenous fascia lata (3.4%) required a secondary bilateral frontalis suspension at the 2- and 3-year time intervals. Conclusions: The authors believe that technique modifications including direct eyelid crease incision and tarsal fixation, conservative fat removal blepharoplasty even in children, lash margin rotation, and rhomboidal configuration with single midline brow incision give improved results of frontalis suspension when compared with conventional techniques.

Trends in Orbital Decompression Techniques of Surveyed American Society of Ophthalmic Plastic and Reconstructive Surgery Members.

Purpose: To assess current members of the American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) regarding preference in surgical techniques for orbital decompression in Graves’ disease. Methods: A 10-question web-based, anonymous survey was distributed to oculoplastic surgeons utilizing the ASOPRS listserv. The questions addressed the number of years of experience performing orbital decompression surgery, preferred surgical techniques, and whether orbital decompression was performed in collaboration with an ENT surgeon. Results: Ninety ASOPRS members participated in the study. Most that completed the survey have performed orbital decompression surgery for >15 years. The majority of responders preferred a combined approach of floor and medial wall decompression or balanced lateral and medial wall decompression; only a minority selected a technique limited to 1 wall. Those surgeons who perform fat decompression were more likely to operate in collaboration with ENT. Most surgeons rarely remove the orbital strut, citing risk of worsening diplopia or orbital dystopia except in cases of optic nerve compression or severe proptosis. The most common reason given for performing orbital decompression was exposure keratopathy. The majority of surgeons perform the surgery without ENT involvement, and number of years of experience did not correlate significantly with collaboration with ENT. Conclusions: The majority of surveyed ASOPRS surgeons prefer a combined wall approach over single wall approach to initial orbital decompression. Despite the technological advances made in the field of modern endoscopic surgery, no single approach has been adopted by the ASOPRS community as the gold standard.

Collateral damage: heat transfer as a possible mechanism of optic nerve injury during neurosurgical intervention.

Purpose: To determine factors associated with increased heat transfer during neurosurgical drilling as a mechanism for optic nerve injury. Methods: On a nonembalmed cadaver, the optic canal was exposed through a standard craniotomy and optic nerve sparing exenteration. The temperature was measured with a thermocoupler during each 30-second continuous drill session using 2 types of neurosurgical drills. The location of the probe, drill site, drill power, and irrigation rate were varied. Results: A <1°C change was measured in the optic canal at all test distances with the Cavitron Ultrasonic Surgical Aspirator and diamond drill. The use of manual irrigation decreased the mean change in temperature (&Dgr;T) in the sphenoid bone from 4.7°C without irrigation to 1.3°C with irrigation. Increasing Cavitron Ultrasonic Surgical Aspirator power from 50% to 80% at an irrigation rate of 4 ml/minute more than doubled &Dgr;T in sphenoid bone from 3.2°C at 50% to 8.1°C at 80%. Increasing irrigation from 2 to 4 ml/minute decreased mean &Dgr;T by −1.1°C (3.2°C at 2 ml/minute versus 2.1°C at 4 ml/minute) at Cavitron Ultrasonic Surgical Aspirator power of 50%, but at Cavitron Ultrasonic Surgical Aspirator power of 80%, increasing irrigation increased mean &Dgr;T by 3.0°C (3.7°C at 2 ml/minute versus 6.8°C at 4 ml/minute). Conclusions: Care must be taken during neurosurgical procedures to decrease heat transfer during drilling to nearby structures. With increase in drill power, there is a noticeable increase in temperature change from baseline. These temperature changes can be mediated by irrigation, although the effect of increasing irrigation rate to suppress the raise in temperature decreases with increasing drill power.

Foreign Body Granuloma Following Orbital Reconstruction with Porous Polyethylene.

Porous polyethylene is commonly used in the orbit for fracture repair and anophthalmic reconstruction; it reportedly has a good safety profile and integrates well into host tissue. Foreign body reaction to porous polyethylene has been reported in facial tissue, but to our knowledge, not in the orbit. The authors report 2 cases of foreign body inflammatory giant cell reaction in patients who underwent orbital fracture repairs with porous polyethylene implants.

A Better Way to Repair Torn Earlobes Using a Modified Z‐Plasty

&NA; The authors have indicated no significant interest with commercial supporters.