Kamel Itani

Maternal orbital hematoma associated with labor

We examined two women with orbital hematomas that occurred during labor. Both women developed sudden diplopia, proptosis, and orbital pain. The location of the hematoma was confirmed by orbital echography and computed tomography. The patients were observed without surgical intervention. Neither patient developed clinical or echographic signs of compressive optic neuropathy. Clinical resolution occurred during the following two weeks. Serial standardized orbital echographic examinations documented resolution of the hematomas.

A systematic review of comparison of upper eyelid involutional ptosis repair techniques: efficacy and complication rates.

Background: The most common form of blepharoptosis is involutional ptosis, commonly caused by the effect of progressive age on the levator aponeurosis. The treatment for this acquired ptosis is strictly surgical. For the plastic surgeon, the ideal lid ptosis repair provides the longest efficacy, the fewest complications and revisions, and, ultimately, the highest functional and cosmetic outcome for the patient. With over 100 different described techniques, there exists a need to make a comparison. A systematic review is considered a higher level of evidence because it is a review designed to be reproducible, with predetermined inclusion and exclusion criteria. To date, there has been no systematic review to study the efficacy and complication rates between different involutional lid ptosis repair techniques. Methods: A systematic search of the English literature published in the PubMed and Cochrane Central Register of Controlled Trials databases yielded trials on comparison of different adult upper lid involutional ptosis repair techniques regarding their efficacy and complication rates. Predetermined inclusion and exclusion criteria were used. Results: This systematic review revealed that there are no randomized, prospective, controlled comparison studies on involutional lid ptosis repair techniques. Conclusions: Although this systematic review revealed a lack of level I data in comparing the different ptosis repair techniques, it is important that the existing studies be reviewed and pooled to improve patient outcomes and to provide direction for future research. In the absence of higher level data studies, the authors propose a treatment algorithm for involutional ptosis repair. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Natural killer/T-cell lymphoma masquerading as orbital cellulitis

We describe 3 cases of natural killer/T-cell lymphoma that presented by masquerading as orbital cellulitis. All of the patients were examined for pain, fever, proptosis, and motility restriction. Computed tomography of the orbits and sinuses revealed orbital soft-tissue swelling without focal abscess in all 3 cases. Bacterial and fungal cultures were negative in each case and all of the patients had initial improvement on systemic antibiotics, only to relapse several days later. Diagnosis of natural killer/T-cell lymphoma was then made based on biopsy of the orbit or sinus. Natural killer/T-cell lymphoma should be considered in cases of orbital cellulitis or sinusitis that fail to respond to traditional management. Biopsy of the affected region should be performed expeditiously to diagnose this condition. Repeat biopsy may be needed.

Mohs Micrographic Surgery of the Eyelid: An Overview of Anatomy, Pathophysiology, and Reconstruction Options

Background Mohs micrographic surgery (MMS) is the ideal treatment for skin cancer removal. The advantages of MMS in the eyelid area include its high cure rate, tissue‐sparing effects, and overall cost effectiveness. Objective To review eyelid anatomy, detail ocular tumors that are amenable to MMS, and examine the surgical repair options commonly used in this area. Materials and methods A review of the literature on MMS of the eyelid was performed with specific reference to ocular anatomy, eyelid malignancy types, and surgical reconstruction. Conclusion Eyelid function is critical for the maintenance of ocular health and vision. MMS is an ideal skin cancer treatment for the delicate structure of the eyelid, where maximal tissue preservation is critical. There are a plethora of reconstruction options to consider after MMS has been performed in this area. The choice of repair and surgical outcome depend, in part, on the surgeons knowledge of eyelid anatomy and his or her ability to assess the repair requirements of the post‐MMS defect. Dermatologic surgeons can effectively work with other specialists to help ensure that their patients receive a cure with restored ocular function and optimal cosmesis.

Blepharoptosis and External Ophthalmoplegia Associated with Long-Term Antiretroviral Therapy

BACKGROUND Long-term antiretroviral therapy (ART) is associated with lipodystrophy, peripheral neuropathy, lactic acidosis, and myopathy. Blepharoptosis, without prior ART association, is usually caused by age-associated involutional ptosis, but it is also seen in mitochondrial myopathies with external ophthalmoplegia, cardiac conduction disturbances, and neurological impairments. METHODS Patients presented over a 2-year period. Four patients underwent surgical blepharoptosis repair. RESULTS Five human immunodeficiency virus type 1-infected patients (median age, 50 years; range, 46-53 years) who were receiving ART presented with severe blepharoptosis; 2 of these 5 also presented with external ophthalmoplegia. Findings included decreased palpebral fissure height (median, 6.5 mm; normal height, 9 mm), mildly impaired levator function (median, 10 mm; normal, >13 mm), and markedly decreased marginal reflex distance (median, 0.5 mm; normal, 4 mm). A greater advancement of the levator aponeurosis was required during surgical repair, a finding consistent more with myogenic than with involutional blepharoptosis. All patients had severe lipodystrophy, which preceded blepharoptosis by a median interval of 4.7 years (range, 2.8-5.7 years). Four patients also presented with peripheral neuropathy and metabolic abnormalities before the onset of blepharoptosis, and 3 had cardiac conduction disturbances. Patients received ART for a median of 7.8 years (range, 4.9-11.2 years), thymidine analogue-containing ART for a median of 7.1 years (range, 1.2-7.9 years), and protease inhibitor-containing ART for a median of 7.1 years (range, 4.9-8.9 years). CONCLUSIONS We report the novel findings of blepharoptosis and external ophthalmoplegia in patients who are receiving ART. Ptosis was preceded by lipodystrophy with long-term use of both thymidine-analogue- and protease inhibitor-containing ART. The findings are most consistent with myogenic ptosis in a generalized mitochondrial myopathy syndrome. Clinicians should also be watchful for other potential myopathic ptosis-associated complications, including proximal weakness, dysphagia, deafness, and cardiac conduction disturbances.

Reconstruction of the Eyelids after Mohs Surgery

A variety of defects of the upper and lower eyelids can be encountered after Mohs surgery. The goals of eyelid reconstruction are to provide structural and functional restoration with an acceptable aesthetic result. A thorough knowledge of the intricate anatomy of the eyelids combined with familiarity of the wide variety of reconstructive options is required to achieve these goals. In this article, we review the anatomy of the eyelids, and we present commonly used techniques for reconstruction of the upper and lower eyelids and the medial and lateral canthal regions after Mohs surgery.

Conservative surgery in orbital teratoma

A case of orbital teratoma is presented. The clinical, X-ray, CT scan, echographic and histopathologic features are discussed. The tumor was excised in toto through a lower eyelid skin approach with preservation of the eye ball and optic nerve. There was no recurrence at one year follow-up.

The value of orbital echography in orbital practice

Summary: Twenty-three consecutive patients with orbital masses who were referred to a major medical center and later had biopsies underwent ophthalmic echographic evaluation. The efficacy of orbital echography was compared with both the clinical evaluation and other orbital imaging methods (computed tomography and magnetic resonance imaging). Echography was successful in all patients (100%) in detecting the orbital mass. The diagnosis was accurate in 18 of 22 patients (82%) echographically, 12 of 14 patients (86%) clinically, and 11 of 13 patients (85%) radiologically when a short differential was attempted. If all the patients examined were considered, echographic evaluation arrived at an accurate diagnosis in 18 of 23 patients (78%), clinical impression was accurate in 12 of 23 patients (52%), and radiologie evaluation was accurate in 11 of 20 patients (55%). In three patients, echography was the only imaging method used. The role of ophthalmic echography in the diagnosis of orbital masses is discussed.

Dissecting lipid metabolism in meibomian glands of humans and mice: An integrative study reveals a network of metabolic reactions not duplicated in other tissues.

Lipids comprise the bulk of the meibomian gland secretion (meibum) which is produced by meibocytes. Complex arrays of lipogenic reactions in meibomian glands, which we collectively call meibogenesis, have not been explored on a molecular level yet. Our goals were to elucidate the possible biosynthetic pathways that underlie the generation of meibum, reveal similarities in, and differences between, lipid metabolism in meibomian glands and other organs and tissues, and integrate meibomian gland studies into the field of general metabolomics. Specifically, we have conducted detailed analyses of human and mouse specimens using genomic, immunohistochemical, and lipidomic approaches. Among equally highly expressed genes found in meibomian glands of both species were those related to fatty acid elongation, branching, desaturation, esterification, reduction of fatty acids to alcohols, and cholesterol biosynthesis. Importantly, corresponding lipid products were detected in meibum of both species using lipidomic approaches. For the first time, a cohesive, unifying biosynthetic scheme that connects genomic, lipidomic, and immunohistochemical observations is outlined and discussed.

Review of Eyelid Reconstruction Techniques after Mohs Surgery

Abstract Mohs micrographic surgery achieves high cure rates while preserving healthy tissue making it the optimal treatment for skin cancer. The goals of eyelid reconstruction after Mohs surgery include restoring eyelid structure and function while attaining acceptable aesthetic results. Given the variety of eyelid defects encountered after Mohs surgery, a thorough understanding of the complex eyelid anatomy as well as an in‐depth knowledge of the numerous reconstructive techniques available are required to accomplish these reconstructive goals. In this article, the authors review eyelid anatomy and discuss a variety of techniques used for the reconstruction of defects involving the periocular region.