Jonathan J. Dutton

Autoimmune Retrobulbar Optic Neuritis

Three patients, all women, ranging in age from 26 to 44 years, had acute retrobulbar neuritis and laboratory evidence of a collagen vascular disorder. These patients were treated with intravenously administered pulse methylprednisolone, and visual acuity recovered in three of four involved eyes. Continued oral administration of prednisone and other immunosuppressive drugs was necessary to maintain vision.

The bioceramic implant: evaluation of implant exposures in 419 implants.

Purpose: To compare the rate of exposure in the immediate 3-month postoperative follow-up period with the rate of exposure after the immediate postoperative period in 419 anophthalmic patients with a bioceramic (aluminum oxide) orbital implant. Methods: This is a retrospective, clinical case series of 419 patients who received a bioceramic orbital implant. All patients who presented to five oculofacial surgeons (D.J., S.G., J.D., S.K., L.M.) from January 1, 2000, to June 1, 2007, who received a bioceramic orbital implant and had a minimum of 3 months of follow-up were included in this study. The authors analyzed age, gender, type of surgery, implant size, peg system, follow-up duration, time of pegging, and problems encountered. The data from the patients with greater than 3 months of follow-up with exposure of the bioceramic implant are detailed in this report. Results: There were 353 patients followed for 3 to 96 months with an average of 30 months of follow-up (median 23 months). Implant exposure occurred in 32/353 bioceramic implants (9.1%). Six of the 32 (19%) exposures occurred during the 90-day postoperative period (average 2.1 months). Twenty-six (81%) exposures occurred outside of the 90-day postoperative period (average 27.5 months, range 4–82 months). Conclusions: Implant exposures can occur anytime postimplant placement. This review discovered an implant exposure rate of 9.1%, with the majority of the exposures occurring after the postoperative follow-up period. Patients with porous orbital implants should be followed on a long-term basis to detect this complication.

Age-related changes in the pediatric human orbit on CT.

Purpose: The purpose of this study was to characterize the relationships among orbital dimensions, globe diameter, and subject age. Methods: A cross-sectional, retrospective analysis of 124 CT scans of subjects with no appreciable orbital or globe disease was performed by 1 observer (G.K.E.). Seventeen length measurements and 5 angle measurements of various aspects of the orbit were obtained. Subjects of similar age were grouped and analysis was performed to define the changes in these parameters in association with age. Results: One hundred twenty-four CT scans of 124 subjects without identifiable globe or orbital disease were included in this study. Twenty-one subjects ≥17 years of age were considered mature adults and grouped together, while the remaining 106 subjects were grouped according to age. Intraobserver variability between orbital measurements was excellent, r > 0.95 (p ⩽ 0.01) for most measurements. There was no difference between right and left orbital measurements, as each was highly correlated to its contralateral counterpart. Globe diameter and all length measurements except globe protrusion increased most rapidly over the first 12 to 24 months and reached 86% to 96% of their respective adult means by age 8 years. Globe diameter and linear orbital measurements were highly correlated. Globe protrusion and measurements of orbital angles exhibited a different pattern. Conclusions: The pattern of human orbital growth is strongly correlated with the pattern of ipsilateral globe growth. This change is most rapid during the first 12 to 24 months of life and maintains a significant pace until reaching 86% to 96% of adult values for most parameters at age 8 years. After this age, the rate slows considerably until maturity. With this attempt to define normal age-related orbital change, the authors report a pattern of growth which may be clinically applicable in the management of pediatric anophthalmos.

Intrapalpebral migration of a rigid gas-permeable contact lens resulting in an eyelid mass

PURPOSEnTo report a case of an eyelid mass that was found to be a rigid gas-permeable contact lens that had migrated into the intrapalpebral tissue and to provide a brief review of the literature on intrapalpebral migration of contact lenses.nnnDESIGNnInterventional case report and review of the literature.nnnMETHODSnThe case is described, and the literature is reviewed.nnnMAIN OUTCOME MEASURESnClinical presentations and mechanisms of intrapalpebral contact lens migration are discussed.nnnRESULTSnA patient had a mass on the left upper lid 3 years after she stopped wearing gas-permeable contact lenses. Orbital magnetic resonance imaging (MRI) showed a curvilinear signal in the area of the mass. Surgical exploration revealed a rigid gas-permeable contact lens entrapped within a fibrous capsule located within the eyelid tissue. A review of the literature revealed several reports of intrapalpebral migration of hard contact lenses, but to our knowledge, this is the first such migrated lens to be imaged on MRI.nnnCONCLUSIONSnIntrapalpebral contact lens should be in the differential diagnosis of upper eyelid mass in patients with a history of contact lens wear. Magnetic resonance imaging may be a useful modality for imaging these rigid gas-permeable lenses.

Embryologic and Fetal Development of the Human Eyelid.

Purpose: To review the recent data about eyelid morphogenesis, and outline a timeline for eyelid development from the very early stages during embryonic life till final maturation of the eyelid late in fetal life. Methods: The authors extensively review major studies detailing human embryologic and fetal eyelid morphogenesis. These studies span almost a century and include some more recent cadaver studies. Numerous studies in the murine model have helped to better understand the molecular signals that govern eyelid embryogenesis. The authors summarize the current findings in molecular biology, and highlight the most significant studies in mice regarding the multiple and interacting signaling pathways involved in regulating normal eyelid morphogenesis. Results: Eyelid morphogenesis involves a succession of subtle yet strictly regulated morphogenetic episodes of tissue folding, proliferation, contraction, and even migration, which may occur simultaneously or in succession. Conclusions: Understanding the extraordinary process of building eyelid tissue in embryonic life, and deciphering its underlying signaling machinery has far reaching clinical implications beyond understanding the developmental abnormalities involving the eyelids, and may pave the way for achieving scar-reducing therapies in adult mammalian wounds, or control the spread of malignancies.

Solitary fibrous tumor of the orbit with multiple cavities.

Solitary fibrous tumors (SFTs) are rare spindle cell neoplasms of mesenchymal origin that most commonly arise within pleura and have also been reported in many extrapleural sites including the orbit. Cavitary changes within SFT of both pleura and extrapleural sites have been documented, but remain very rare. To the authors’ knowledge, the third known case of an orbital solitary fibrous tumor containing large pseudocystic cavities is described. MRI demonstrated a heterogeneous enhancing mass with multiple cavities. Excisional biopsy revealed solid tumor with large cavities filled with straw-colored fluid and tumor cells that stained positive for CD34 and CD99 antigens, consistent with SFT. The patient had an uncomplicated postoperative course with no sign of recurrence and resolution of the proptosis after 12 months of follow up. SFT are rare benign orbital neoplasms that rarely present with cavitary changes. Current treatment options include complete surgical excision, which was performed in this case. Close follow up is advised to monitor for recurrence.

Institutional Review Boards, declaration of Helsinki, and HIPAA regulations.

335 D the past several years, there has been some confusion regarding requirements for institutional review board (IRB) oversight of research studies involving human subjects. This confusion has stemmed, in part, from the Ophthalmic Plastic and Reconstructive Surgery (OPRS) Information for Authors (IFA) and also from the great variability of ethical review requirements among medical journals. Our IFA states that all research studies involving human subjects, humanderived materials, or human medical records must obtain IRB approval and state so in the Methods section of the article. It goes on to say that if the study was conducted without oversight from a formal IRB or equivalent ethical committee, then authors should include a statement that the study adhered to the tenets of the Declaration of Helsinki. This has sometimes been interpreted to mean that the Helsinki statement is an acceptable substitute for formal independent IRB review. This is not the case. In fact, a central principle of the Declaration of Helsinki is that research protocols should be reviewed by a specially appointed committee independent of the investigator and any research sponsor. For OPRS, the Helsinki statement by itself is intended only for those situations where a formal ethics review committee is not available or not required by your institution. But, in all cases where an author is affiliated with an academic institution, medical center, hospital, or other organization with an IRB, or where the patient data were collected and are maintained under the purview of such institution, IRB review is required, unless exempt under Department of Health and Human Services (DHHS) regulations. The purpose of this editorial is to clarify the often confusing federal regulations governing oversight of human research studies and to serve as a reference for future authors submitting manuscripts to OPRS. Ophthalmic Plastic and Reconstructive Surgery, like all medical journals, aspires to select, through the peer review process, the highest quality science. While peer review is intended to improve the accuracy, clarity, and completeness of published articles and to help editors decide which articles to publish, peer review alone does not guarantee scientific quality and certainly cannot verify ethical standards in the execution of human subject research. Any journals’ reputation depends on the trust of its readers, authors, reviewers, editors, funding agencies, and administrators of public health policy in its printed and digital content. Therefore, almost every aspect of the editorial and review process involves important ethical principles and decisions. To help with this important function, most medical journals rely on external independent review committees, often referred to as IRBs or Research Ethics Committees, to evaluate research studies and to protect the well-being and confidentiality of human subjects. With the ever-increasing scrutiny of the media and government agencies, journals are more inclined to enforce research polices, and in the future, authors can anticipate that their submission will be required to meet an expanding array of ethical standards.1 In 2001, Roggin et al. reviewed 149 prospective studies on pediatric patients in 7 journals, most of which were interventional and funded studies, and found <25% had any documentation of IRB approval. An earlier study by Amdur and Biddle examined 102 medical journals and not only found great variability in requirements for ethical review of human research but also noted that only 47% of these journals required any IRB approval for studies involving human subjects and 24% provided no ethical guidelines to authors. In 2008, Freeman et al. repeated the study of Amdur and Biddle and found some improvement, with 83% of medical journals requiring IRB approval, and only 8% providing no ethical guidelines. However, other studies published in the past 5 years have reported 24% to 80% of research studies failing to mention ethical committee oversight. There still remains considerable variation in the extent of ethical requirements among journals and weak enforcement of ethical oversight for human research.

Bilateral spontaneous subperiosteal orbital hemorrhages following endoscopic retrograde cholangiopancreatography.

Spontaneous subperiosteal orbital hemorrhage is rare. The authors describe a case of acute bilateral eyelid swelling, eyelid ptosis, and double vision in a patient immediately following endoscopic retrograde cholangiopancreatography. CT revealed bilateral subperiosteal orbital hemorrhages. The patient demonstrated no signs of optic nerve compromise, and the hemorrhages resolved spontaneously without sequela. Previous reports in the literature have documented subperiosteal hemorrhages following increased intracranial venous pressure, coagulopathies, and prone positioning during procedures. To the authors knowledge, subperiosteal orbital hemorrhages have not been previously described following endoscopic retrograde cholangiopancreatography. Ophthalmologists and gastroenterologists should be aware of this potential complication associated with this procedure.

Predicting the Surgical Margin of Resection in Periocular Cutaneous Neoplasms and the Significance of Reconstruction Following Mohs Micrographic Surgery.

Purpose: To evaluate the features of periocular cutaneous malignancies that may contribute to larger surgical defects or require more complex reconstructive procedures. Methods: A retrospective review of 181 patients with biopsy proven periocular cutaneous malignancies seen between April 2005 and September 2010, and undergoing Mohs micrographic surgery was performed. The longest horizontal and vertical diameters of the tumor and the post-Mohs surgical defect were measured in each patient. These measurements were used to calculate the relative margin of resection (MOR) required for tumor eradication as well as the size of the surgical defect. The date of surgery, histologic diagnosis and location of the tumor, type of reconstruction, and the presence of recurrence were also recorded. Results: The average MOR for all tumor subtypes taken together was 3.4u2009mm horizontally and 2.6u2009mm vertically for basal cell carcinomas (BCCA). The post-Mohs defect area was 3.2 times greater than the preoperative tumor area for all BCCA subtypes, and 3.9 times greater for morphea type (p = 0.8083). The average MOR for squamous cell carcinomas (SCCA) was 5.1u2009mm horizontally and 3.7u2009mm vertically. The post-Mohs defect area was 3.8 times greater than the preoperative tumor area for SCCAs. When comparing the preoperative horizontal tumor diameter to the horizontal MOR of BCCAs and SCCAs, the correlation was 0.23 (p < 0.0001) and 0.31 (p < 0.0001), respectively. While the average MOR was within standard limits, a significant number of tumors required a greater MOR. On review of the data, 30.6% of patients with BCCA required a MOR greater than 3u2009mm, 17.3% of patients with BCCA required a MOR greater than 4u2009mm, and 29.1% of patients with SCCA required a MOR of greater than 5u2009mm. Tumors located at the lateral canthus required the largest MOR (p < 0.01), while those on the lower eyelid were associated with the smallest MOR in BCCAs. As expected from anatomical considerations, tumors at the medial canthus required significantly more complex reconstruction procedures (p < 0.01). An ordered logistic regression model demonstrated that BCCA preoperative clinical tumor surface area was a significant indicator for the degree of reconstruction required (p < 0.01). Conclusions: Standard 3u2009mm to 4u2009mm MOR for BCCAs, and 5u2009mm MOR for SCCAs could result in an unacceptable risk of tumor recurrence if the surgical margins are not examined histologically. With increasing preoperative tumor size, there is an increase in the MOR required for BCCA and SCCA, supporting that large tumors require a greater MOR.

Chronic, recurrent dacryocystitis from a BB in the lacrimal sac.

Metallic foreign bodies in the lacrimal outflow tract are a rarely reported cause of nasolacrimal duct obstruction. Among the few cases in the literature, 1 consisted of a BB in the nasolacrimal duct. This case report presents a second case of chronic, recurrent dacryocystitis in a child, which occurred secondary to a BB that had become lodged in the lacrimal sac. The metallic foreign body was identified on CT and successfully removed surgically. Exogenous sources of lacrimal sac foreign bodies should be considered in patients with a history of periorbital trauma and signs of chronic nasolacrimal duct obstruction. Evaluation with CT is recommended. Removal of the foreign body, with dacryocystorhinstomy as needed, is curative.