Joseph C. Flanagan

Lacrimal sac tumors

Tumors of the lacrimal sac are a rare entity in ophthalmology, but represent a potentially life-threatening situation that can easily be overlooked. This paper will review the literature and describe clinically and pathologically the more common types of lacrimal sac tumors, and give a description of the less common types of primary and secondary tumors of the lacrimal sac and a case presentation.

Retrobulbar anesthesia and retinal vascular obstruction.

The cases of three patients who developed combined central retinal artery/vein obstruction secondary to retrobulbar anesthesia are presented. In one case the obstruction was presumably present immediately after surgery, while in the other two it was observed to evolve over a period of several days. A dilated optic nerve sheath was demonstrated by contact B-scan ultrasonography in two cases and by computerized tomography in the third case, suggesting intravaginal sheath hemorrhage as a common underlying pathophysiologic process. Partial return of vision was evident in the latter case following orbitotomy with optic nerve sheath decompression.

The Diagnosis and Management of Epithelial Tumors of the Lacrimal Sac

Five primary epithelial lesions of the lacrimal sac representing a range of epithelial tumors are presented. The benign lesions initially presented without pain or significant mass but with epiphora and a bloody discharge. The malignant lesions presented insidiously, were large, firm masses and displayed overlying skin telangiectasis rather than the diffuse erythema of dacryocystography revealed a sac partially obstructed by a subtotal space-occupying mass in benign tumors and completely obstructed with malignant lesions.

Cavernous Hemangiomas of the Orbit

Patients with cavernous hemangioma of the orbit seen at the Wills Eye Hospital for the 10-year period, 1972-1981 were reviewed in a retrospective manner. This benign vascular tumor most typically presented as unilateral painless proptosis in a middle-aged woman. The duration of symptoms was between 6 months and 2 years. CT scanning demonstrated a well-circumscribed, homogeneous tumor without bony erosion. Ultrasonography typically showed good sound transmission with moderate internal reflectivity. It is not possible to distinguish clinically a benign cavernous hemangioma from the rare and potentially lethal hemangiopericytoma. Since recurrence and metastasis of hemangiopericytoma may be related to incomplete excision, fastidious dissection and removal of all tumors thought to be cavernous hemangioma before surgery is advised for fear the final pathology may indicate hemangiopericytoma.

Canalicular laceration. An 11-year epidemiologic and clinical study.

From 1977 through 1987, a total of 222 patients (166 male and 56 female patients) underwent surgical repair of canalicular laceration at Wills Eye Hospital. Demographic and clinical information were collected from the medical records and by written questionnaire or telephone interview. Most injuries occurred in children or young adults (median age, 20 years). Overall, blows from fists was the most common cause of injury (52 patients, 23.4%). Dog bites or scratches were the most frequent causes among children. A total of 147 injuries (66.2%) involved the lower eyelid, 61 (27.5%) the upper eyelid, and 14 (6.3%) the upper and lower eyelids on the same side. Constant or stress epiphora occurred postopera-tively significantly more often among patients with combined upper and lower canalicular injuries (61.5%) than among those with single canalicular laceration (19.7%) (p < 0.01). Analysis with logistic regression showed epiphora to be more common among adults than children (p < 0.05) when the pigtail probe had been used intraop-eratively (p < 0.05), or when no canalicular stent had been placed at the time of surgical repair (p < 0.05). No statistically significant associations were found between sex, cause of injury, type of canalicular stent, or time interval from injury to surgical repair and presence of postoperative epiphora.

The Carney complex with ocular signs suggestive of cardiac myxoma.

We treated a patient who had ophthalmic findings of the Carney complex that led to a search for and the discovery of asymptomatic cardiac myxoma. Substantial morbidity and mortality are associated with the complex because of the occurrence of cardiac myxoma. Facial and eyelid lentigines, conjunctival and caruncle pigmentation and eyelid pigmentation may precede signs or symptoms of cardiac myxoma. A study of the patients primary relatives disclosed manifestations of the complex transmitted in a manner consistent with mendelian autosomal dominant inheritance.

The Histopathology of Involutional Ectropion

Twenty eyelid specimens from patients with involutional ectropion, obtained by full-thickness horizontal shortening procedures, were examined histopathologically by light and electron microscopy and compared with six normal eyelids from exenteration specimens. Paralytic, cicatricial, and congenital ectropions were excluded from the study. The main histopathologic features included: (1) collagen degeneration and elastosis of the tarsal plate; (2) increased amounts of adipose tissue in the distal tarsus and capsulopalpebral fascia; (3) subacute inflammation and epidermidalization of the tarsal conjunctiva; (4) focal degeneration, fibrosis and elastosis of pretarsal orbicularis, and occasionally minimal change in the muscle of Riolan; and (5) arteriosclerosis of the marginal artery. The combination of these histopathologic changes characterize and may contribute to the development of ectropion of the eyelid associated with aging.

Gaze-induced amaurosis from central retinal artery compression

Color Doppler imaging was used to evaluate a patient with gaze-induced amaurosis caused by an intraconal orbital mass. The time-velocity waveform demonstrated abnormally high vascular resistance in the central retinal artery of the affected eye in the primary position. Abduction of the affected eye resulted in transient visual loss with an unreactive pupil. This same maneuver during color Doppler imaging resulted in a dramatic reduction of blood flow in the central retinal artery. Two months after surgical excision of the mass, the gaze-evoked amaurosis was no longer present, and color Doppler imaging demonstrated normal blood flow in the central retinal artery. This suggests that impaired retinal and optic nerve blood flow are responsible for gaze-induced amaurosis from compressive orbital lesions.

Complications associated with silicone intracanalicular plugs.

Purpose To assess American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS) member physicians’ experiences with complications associated with silicone intracanalicular plugs and publicize risks associated with this device. Methods Two case reports are presented. A survey was sent to 420 ASOPRS member physicians, questioning them on their experiences with complications associated with silicone intracanalicular plugs. Results We present two case reports of complications associated with migration of intracanalicular plugs. In the first case, a 41-year-old man underwent serial insertion of seven intracanalicular plugs in one eye over several years; he had a 3-month relapsing course of Nocardia asteroides canaliculitis, dacryocystitis, and cellulitis requiring systemic antibiotics and multiple surgeries. In the second case, a 72-year-old woman had acute dacryocystitis, eventually necessitating dacryocystorhinostomy; at surgery, an intracanalicular plug was discovered in the lacrimal sac. One hundred fifty-nine usable survey responses were obtained. Sixty-one percent of respondents reported various complications including tearing, canaliculitis, and dacryocystitis. Fifty-one percent of respondents performed surgery to treat complications associated with silicone intracanalicular plugs. Conclusions Silicone intracanalicular plugs may be difficult to remove and may be associated with significant lacrimal complications.

Ocular motility disorders secondary to sinus surgery.

Sinus surgery has multiple potential ocular complications including visual loss, diplopia, infection, hemorrhage, and epiphora. We report six patients with ocular motility problems secondary to sinus surgery, review the literature on ocular motility disorders secondary to sinus surgery, and propose an approach for management of those ocular motility problems following sinus surgery. Intranasal sinus surgery was found to be the most common procedure resulting in injury to an extraocular muscle and the ethmoid sinus the most common structure being operated on when injury occurred. The medial rectus was the muscle most commonly injured and it had the poorest prognosis for recovery of functional vision free of diplopia. Optimal timing for repair depends on the structure injured, but early recognition and management appear to be a key to the best outcome for these injuries.