John D. Bullock

Survival factors in rhino-orbital-cerebral mucormycosis.

Mucormycosis is a highly aggressive fungal infection affecting diabetic, immunocompromised, and, occasionally, healthy patients. This infection is associated with significant mortality. We have reviewed 208 cases in the literature since 1970, 139 of which were presented in sufficient detail to assess prognostic factors, and added data from six of our patients. The histories of these 145 patients were analyzed for the following variables: 1) underlying conditions associated with mucormycotic infections; 2) incidence of ocular and orbital signs and symptoms; 3) incidence of nonocular signs and symptoms; 4) interval from symptom onset to treatment; and 5) the pattern of sinus involvement seen on imaging studies and noted at the time of surgery. Factors related to a lower survival rate include: 1) delayed diagnosis and treatment; 2) hemiparesis or hemiplegia; 3) bilateral sinus involvement; 4) leukemia; 5) renal disease; and 6) treatment with deferoxamine. The association of facial necrosis with a poor prognosis fell just short of statistical significance, but appears clinically important. This is the first review that documents the heretofore intuitive claim that early diagnosis is necessary to cure this disease. Standard treatment with amphotericin B and aggressive surgery are reviewed and adjunctive therapeutic modalities are discussed, including local amphotericin B irrigation, hyperbaric oxygen, and optimizing the immunosuppressive regimen in transplant patients. Hyperbaric oxygen was found to have a favorable effect on prognosis. In addition, possible treatment options for patients with declining renal function are reviewed.

The spread of odontogenic infections to the orbit: Diagnosis and management

Four cases of orbital cellulitis following the extraction of maxillary molars are presented. The time interval between dental extraction and development of orbital symptoms ranged from two hours to 13 days. All patients presented with fever, elevated leukocyte counts, and radiologic evidence of acute ipsilateral paranasal sinus infection. In addition, one patient presented with meningitis. Predisposing factors in three patients included nephrotic syndrome with chronic antral inflammation, pregnancy with upper respiratory tract infection, and heroin addiction. Sequelae included empyema and death, severe loss of vision, and blindness with ptosis and exotropia. One patient recovered completely. The anatomic pathways by which dental infection can spread to the orbit are discussed, and general therapeutic considerations are emphasized.

Necrobiotic xanthogranuloma with paraproteinemia: case report and a pathogenetic theory

Necrobiotic xanthogranuloma with paraproteinemia is a clinical and histopathological entity characterized by xanthelasma-like lesions in the periorbital region and elsewhere, paraproteinemia, leukopenia, and an elevated erythrocyte sedimentation rate. Multiple myeloma has been reported as an accompanying feature in several cases. We examined a patient with necrobiotic xanthogranuloma and multiple myeloma in whom an IgG kappa monoclonal protein was identified in serum, urine, bone marrow, and bilateral periorbital lesions. We speculate that increased serum immunoglobulins complexed with lipid may be deposited in the skin, leading to a foreign body giant cell reaction and the subsequent characteristic histopathologic features of necrobiotic xanthogranuloma.

Lacrimal Ductal Cysts

Cyst formation can occur in any location where lacrimal gland tissue is present. A new classification is proposed based on these locations: palpebral lobe cysts (simple dacryops); orbital lobe cysts; cysts of the accessory lacrimal glands of Krause and Wolfring; and cysts of ectopic (choristomatous) lacrimal glands. The characteristic clinical presentation, histopathology, and treatment of these lacrimal ductal cysts is described.

Ophthalmic Manifestations of Metastatic Breast Cancer

Metastatic breast cancer is the most common primary tumor metastasizing to the ocular structures. An analysis of 30 patients demonstrated a wide spectrum of ophthalmic manifestations including cranial nerve involvement, brain involvement with papilledema, Horners syndrome, and choroidal and orbital tumors. The mean age of patients presenting with an ophthalmic sign was 54 years and the mean interval from the diagnosis of breast cancer to the development of the ophthalmic sign was 4.9 years. The carcinoembryonic antigen (CEA) was useful in confirming the diagnosis of metastatic disease as it was elevated in 18 of the 22 patients in whom it was measured. The estrogen receptor assay, performed on metastatic tissue removed from the orbit, can indicate the sensitivity of the breast cancer to hormonal therapy.

An Experimental Study to Compare Methods of Eyelash Ablation

Epilation, electrolysis, cryotherapy, and argon laser thermal ablation were used to remove eyelashes of rabbits. Epilation and electrolysis were done in the standard fashion. Nitrous oxide cryotherapy was applied in a double rapid-freeze/slow-thaw manner for either 30 or 60 seconds. Argon laser settings were 1 W, 50-micron spot size, and durations of 0.2, 0.5, or 1.0 second. The rabbits were euthanized immediately, 24 hours, 2 weeks, or 3 months after the procedure. Epilation was followed by total regrowth of eyelashes within 2 weeks. Electrolysis showed focal destruction of follicles with variable regrowth. Cryotherapy resulted in moderate-to-severe eyelid scarring with minimal regrowth. Argon laser thermal ablation produced focal necrosis and variable follicle destruction. Argon laser thermal ablation may be a suitable alternative to electrolysis or cryotherapy in selected cases of trichiasis.

Orbital varix thrombosis.

Venous disease of the orbit is a rare occurrence which can become manifest in a variety of ways including an arteriovenous aneurysm or fistula, a cavernous sinus or superior ophthalmic vein thrombosis, and an orbital varix, with and without thrombosis. Three patients had proptosis due to orbital varix thrombosis. The onset, degree of pain, and presence of diplopia were all variable. In two of three patients, computed tomographic (CT) scans showed lesions reminiscent of cavernous hemangiomas. The clinical, radiographic, surgical, and histopathologic features of this entity are described and discussed and a hypothesis is proposed to explain the pathophysiology of orbital varix thrombosis.

Ocular Explosion after Peribulbar Anesthesia: Case Report and Experimental Study

PURPOSE A peribulbar anesthetic injection for cataract surgery produced a 10.5-mm scleral laceration and lens extrusion. This study sought to recreate this unfortunate clinical situation. METHODS Twenty-one human eye bank eyes were ruptured by intraocular injection of saline through Atkinson needles. The hydrostatic pressure required for globe rupture was measured by three different techniques in seven globes. RESULTS Forty-eight percent of the scleral lacerations were equatorial and 52% were perilimbal. Lens extrusion occurred with three of the perilimbal lacerations. Rupture pressures by each technique averaged 3065, 4972, and 5648 mmHg. CONCLUSION Peribulbar injection can produce inadvertent ocular explosion.

Metastatic Eyelid Carcinoma

Two cases of carcinoma metastatic to the eyelid are described. The first was derived from a lung primary diagnosed two months prior and presented as a solitary tender mass mimicking an acutely inflamed recurrent chalazion. The second case was the initial manifestation of a stomach carcinoma, presenting as a solitary painless nodule. Both were part of generalized metastatic disease; survival was six weeks and five months, respectively, after eyelid tumor presentation. Excisional biopsy was effective palliation in the first case, but multiple operations were required in the second. The clinicopathologic features are discussed and the prior reported cases reviewed.

Optic nerve sheath meningoceles. Clinical and radiographic features in 13 cases with a review of the literature.

Thirteen patients with dilated intraorbital optic nerve sheaths with an expanded, patulous cerebrospinal fluid (CSF) space were studied with high-resolution computed tomography (CT) or magnetic resonance imaging (MRI). Eleven patients had bilateral findings. Headache or visual complaints, or both, were present in all patients. Signs of optic nerve dysfunction were present in eight patients. Three patients had visual acuity worse than 20/200. Cerebrospinal fluid pressure was mildly elevated in two patients. Three patients underwent a surgical procedure; visual acuity improved in one. The authors propose the term meningocele for this condition and suggest MRI with fat-suppression techniques and off-axis sagittal views as the radiographic procedure of choice.