Lynnette M Watkins

The Evolution of Endonasal Dacryocystorhinostomy

Dacryocystorhinostomy is an important treatment in the relief of tearing. Through the years, there have been several advances in this procedure. Once performed only from an external approach, the advent of rigid endoscopes and endoscopic instrumentation has made the endonasal approach a reality. Advantages of the endonasal approach include lack of a cutaneous incision and excellent visualization of intranasal pathology, which is often the cause of dacryocystorhinostomy failure. Preoperative evaluation including a detailed medical history, physical examination with office endoscopy, and imaging, as well as postoperative care are important. Surgical technique with detailed knowledge of intranasal anatomy and meticulous attention to hemostasis are critical. Endonasal laser-assisted dacryocystorhinostomy is also performed today, and special preoperative considerations and key features of the lasers available are important in the selection of a laser for tissue or bone ablation during the procedure. Endoscopic conjunctivodacryocystorhinostomy is performed today, and given the critical nature of proper length and placement of the Jones tube intranasally, provides the significant advantage of intranasal visualization. Endoscopic dacryocystorhinostomy in children is also performed today; however, challenges such as small nasal anatomy and maintenance of the intranasal osteomy postoperatively in a child are significant issues.

Orbital fractures in children.

Purpose To describe the demographics, etiologic factors, clinical presentations, and outcomes of orbital fractures in children. Methods This was a retrospective case series of 96 consecutive patients under 18 years of age with orbital fractures presenting to the Massachusetts Eye and Ear Infirmary, including both hospitalized and nonhospitalized patients. Results Orbital fractures in children were most frequently the result of sports, assault, or motor vehicle accident. The majority of patients did not require hospitalization and were treated as outpatients. The medial wall and floor of the orbit were the most frequent locations of fracture. Approximately half of the patients in this series required surgery, most often for entrapment. There were no cases of persistent diplopia in patients in whom surgery was performed or was not indicated. Associated ocular injuries were observed in half of the patients. Conclusions In this series of hospitalized and nonhospitalized patients, orbital fractures in children had a location pattern similar to that most frequently observed in adult patients (floor and medial wall). Orbital fractures in children frequently require surgery. The high prevalence of ocular injury in children with orbital fractures emphasizes the need for a comprehensive ophthalmic evaluation.

Bilateral cavernous sinus thromboses and intraorbital abscesses secondary to Streptococcus milleri.

PURPOSE To report the first case of bilateral cavernous sinus thromboses and bilateral intraorbital abscesses secondary to Streptococcus milleri. STUDY DESIGN Single interventional case report. INTERVENTION AND TESTING The findings of the ophthalmic evaluation, radiographic imaging, medical and surgical intervention, specimen cultures, and clinical course were analyzed. RESULTS A 17-year-old female had bilateral proptosis, decreased vision in the left eye, and altered mental status at presentation. An orbital compartment syndrome developed in the left eye and purulent material was present after lateral canthotomy, suggestive of an intraorbital abscess. Magnetic resonance imaging (MRI) scans revealed bilateral cavernous sinus thromboses, and subsequent computed tomographic (CT) scans revealed bilateral intraorbital abscesses in the setting of acute ethmoid and sphenoid sinusitis. Antibiotic treatment and surgical drainage of the orbital abscess and sinuses was performed, and specimen cultures revealed S. milleri. After surgery, the patient experienced hearing loss and a right internal capsule infarct, in addition to complete vision loss in the left eye. A second intraorbital abscess developed in the right eye and was drained surgically. The vision remained 20/20. CONCLUSIONS Streptococcus milleri is a virulent organism with a propensity to form abscesses in multiple areas of the body and should be considered as a possible etiologic agent in abscess formation of the orbit and cavernous sinus thrombosis.

Ocular adnexal lymphoma of the extraocular muscles: case series from the University of Iowa and review of the literature.

Purpose: To review and statistically analyze the data of patients with discrete involvement of the extraocular muscles with ocular adnexal lymphoma from the tumor registry at the University of Iowa and to compile with current cases in the literature. Methods: The records of patients with biopsy-proven orbital lymphoma at the University of Iowa Hospitals and Clinics Department of Ophthalmology and the Tumor Registry of the University of Iowa were reviewed. A review of the literature and meta-analysis were conducted. Results: Eleven patients were identified with biopsy-proven ocular adnexal lymphoma with discrete involvement of the extraocular muscles at the University of Iowa. Additionally, 46 patients were identified in the literature with clinical and radiographic involvement of the extraocular muscles, 31 (67%) with biopsy-proven involvement. In the combined group of 57 patients, 16 (35%) of 45 patients with histopathologic documentation had lymphomas classified as extranodal marginal zone lymphomas. Twenty-five (67%) of the 37 patients with tumor-staging documentation had no extraorbital involvement. Conclusions: Ocular adnexal lymphoma with discrete extraocular muscle involvement is rare. Most lymphomas found in this area of the orbit are subtypes of B-cell lymphoma. This disease should be included in the differential diagnosis of enlarged extraocular muscles.

Orbital Granulocytic Sarcoma in an Elderly Patient

PURPOSE To report a 71-year-old woman with acute myelogenous leukemia in remission who developed orbital granulocytic sarcoma. METHODS The patient was referred for acute proptosis and decreased vision of the right eye. Computed tomography of the orbits demonstrated a right extraconal mass compressing the optic nerve. A right lateral orbitotomy was performed, and a portion of the mass was excised for diagnostic purposes and orbital decompression. RESULTS Histopathologic and immunohistochemical evaluation disclosed orbital granulocytic sarcoma. With chemotherapy and radiation, vision remained stable and right proptosis resolved. CONCLUSIONS Orbital granulocytic sarcoma is usually diagnosed in children with a history of acute myelogenous leukemia. This case demonstrated that this entity may also occur rarely in older patients with a history of acute myelogenous leukemia.

Two cases of orbital lymphangioma associated with vascular abnormalities of the retina and iris

PURPOSE To report 2 patients with combined intraocular and orbital vascular abnormalities. DESIGN Two interventional case reports. MAIN OUTCOME MEASURES Clinical and pathologic findings. INTERVENTION/TESTING: Orbitotomy, fluorescein angiography, magnetic resonance imaging, and radiation therapy. RESULTS Two patients presented with vision loss, intermittent proptosis, and cosmetic deformity. These patients had orbital lymphangioma, ipsilateral retinal and iris vascular malformations, and smaller corneal diameter on the affected side. CONCLUSIONS The coexistence of these diverse vascular anomalies supports the established hypothesis of pluripotential orbital vascular anlagen. Disruptive influences of various types during embryogenesis or development may produce a variety of congenital orbital and intraocular vascular malformations.

Tension orbital pneumocele secondary to nasal obstruction from cocaine abuse: a case report.

Cocaine abuse is associated with many well known complications: hypertensive crisis, ventricular arrhythmias, cardiopulmonary arrest, clonic-tonic convulsions, and hyperpyrexia. Chronic abuse can cause septicemia with endocarditis, hepatitis, pulmonary insufficiency, and psychiatric disturbances.1 More common otolaryngologic complications include nasoseptal perforation, chronic sinusitis, and destruction of the bony sinus walls. Less common complications include cervical emphysema, pneumomediastinum, and nasolacrimal duct obstruction. Here we present an unusual case of potentially vision-threatening tension orbital pneumocele secondary to aggressive nose blowing against nasal obstruction caused by cocaine abuse.