Mark R. Levine

The 1998 Wendell Hughes Lecture. Evisceration: is sympathetic ophthalmia a concern in the new millennium?

PURPOSE To investigate a possible relationship between evisceration and sympathetic ophthalmia. METHODS Data from Mt. Sinai Medical Center and University Hospitals of Cleveland were collected and histopathologic specimens were reviewed for 51 of 90 patients who underwent evisceration between 1980 and 1996 and who returned for follow-up examinations. Additionally, a survey was sent to members of the American Society of Ophthalmic Plastic and Reconstructive Surgery, the Uveitis Society, and the Eastern Ophthalmic Pathology Society to determine the number of enucleations and eviscerations performed and the documented incidence of sympathetic ophthalmia after evisceration. RESULTS No clinical or histopathologic evidence of sympathetic ophthalmia after evisceration was found among patients treated at the two medical centers. The collective surveys showed a strong preference for enucleation over evisceration, but did not document evidence of sympathetic ophthalmia after evisceration. CONCLUSIONS Evisceration is an effective and safe procedure with a low risk for sympathetic ophthalmia.

Primary Mucinous Sweat Gland Carcinoma of the Eyelid Simulating Metastatic Carcinoma

A 78-year-old man suffered an unusual variant of sweat gland carcinoma of the eyelid. This disorder is seldom recognized, and is frequently confused with inflammation, benign neoplasms, and metastatic carcinomas. On the basis of clinicopathologic and ultrastructural features found by both light and electron microscopy, we diagnosed sweat gland carcinoma of the eyelid. We considered the possibility of metastasis from a primary carcinoma elsewhere in the patient.

Subperiosteal Hematoma of the Orbit: Case Presentation

Summary: A 14-year-old boy was referred with complaints of decreased vision, pain, and diplopia that developed in his right eye after trauma. Radiologic studies showed an orbital roof fracture with an associated subperiosteal hematoma. Orbital exploration with surgical drainage of the hematoma and roof fracture repair was performed. Postoperatively, he experienced complete visual recovery with resolution of his proptosis and diplopia. Subperiosteal hematomas of the orbit should be considered in the differential diagnosis of acute unilateral proptosis after trauma. The authors suggest that early intervention results in rapid patient recovery.

Nonpalpable breast carcinoma presenting as orbital infiltration: case presentation and literature review.

Purpose To report orbital metastasis as the presenting sign of a nonpalpable breast carcinoma in a 61-year-old woman. Methods Case report and literature review. Results A uterine metastasis of unknown origin found 11 years prior was retrospectively identified as having the same histopathology as the breast and orbit tumors. Eight years after her orbital presentation, the patient was diagnosed with and underwent resection of a metastatic adenocarcinoma of the colon, consistent with lobular adenocarcinoma of the breast. Conclusions This is a rare case of an orbital metastatic adenocarcinoma preceding the diagnosis of a nonpalpable primary breast carcinoma.

Primary intraosseous hemangioma of the orbit; Report of a case and review of literature.

Orbital intraosseous hemangiomas are rare entities, with only 15 previously reported. We review these and present our own. They are benign, vascular tumors, typically found in the frontal, ethmoid, or zygomatic bones. They tend to present in the 4th or 5th decades as a mildly painful orbital rim mass. Ocular findings may be absent or severe, including blindness. These tumors have characteristic, although not always present, roentgenologic features that differentiate them. Our case is unusual in that it is the oldest patient reported, demonstrates bilateral lesions, and did not exhibit classic x-ray findings. We report imaging these lesions with magnetic resonance imaging with nonspecific results. The pathology of orbital hemangiomas is presented, with the most common being the cavernous type. Because these tumors may bleed when entered, block excision with normal margins is the treatment of choice. Radiation therapy has specific indications for nonresectable lesions. Prognosis is uniformly good, if treated.

Metastatic melanoma within and to the conjunctiva.

Two patients with epibulbar juxtalimbal primary conjunctival melanomas experienced local intralymphatic metastases to the inferior cul-de-sac, and a hematogenous metastasis to the conjunctiva developed in five other patients with cutaneous melanomas. Whether reflective of a local or distant metastasis, all of the lesions histopathologically were located in the substantia propria, and were separated from the overlying epithelium by a thin mantle of collagen. There was no evidence of atypical intraepithelial melanocytic proliferation, as would be expected in association with a primary conjunctival melanoma. Two of the cutaneous metastases exhibited a binodular or multinodular appearance that correlated histopathologically with variably confluent micronodules suggestive of the origin of the clinical lesion from a shower of tumor cell emboli. Patients with local intralymphatic spread from a primary conjunctival melanoma may experience additional lesions in the conjunctival sac or eyelid skin and are at risk for regional or distant metastases. They should be examined closely several times a year. The patients with the distant metastases all had their previously diagnosed primary cutaneous tumors on the truncal skin (a similar tendency emerges from a review of previous ocular cases), typically had myriad other cutaneous lesions, and two of them had a neoplastic iridocyclitis and vitreitis. These patients tended to die of the disseminated tumors within 1 year after conjunctival metastases developed.

Mersilene mesh sling as an alternative to autogenous fascia lata in the management of ptosis.

Purpose To evaluate the use of Mersilene mesh as a brow suspensory material and to compare it clinically against autogenous fascia lata.Methods A prospective study was carried out in which 80 eyes of 56 patients with ptosis and absent, poor or abnormal levator function were operated on. The patients were divided into two groups. In 46 eyes of 32 patients Mersilene mesh was used and in 34 eyes of 24 patients autogenous fascia lata was used. The results were recorded and analysed.Results The age range for the Mersilene group was larger than for the fascia lata group and female patients preferred Mersilene over fascia lata. The improvement in lid height was significant in all cases in both groups. The complication rates were similar in the two groups and the mesh was well tolerated by the patients. No cases of infection, sling exposure or extrusion occurred with the use of Mersilene. Lid lag and lagophthalmos occurred as a complication of the procedure itself and not the type of the sling material. The mean follow-up period was 33.8 months for both groups.Conclusion We believe that Mersilene mesh is an effective alternative to autogenous fascia lata when the use of fascia lata is felt inappropriate.

Surgical treatment of thyroid-related lid retraction : a new variation

We describe a cutaneous approach for retraction of the upper eyelid which incorporates a levator aponeurotic/Muellers muscle recession with maintenance of the normal orbital septum levator aponeurosis anatomy. With success defined as asymmetry between the two eyelids of 1 mm or less, with a marginal reflex distance as close to 4 mm as possible, this technique was successful in 87% of 15 consecutive patients. All patients reported improved comfort. This approach is quick and easy, bleeding is minimal, height and contour are predictable, the upper eyelid crease is preserved, and spacers are avoided, with less postoperative eyelid thickening and reaction.

Malignant Melanoma of the Lacrimal Sac

The case of an 80-year-old woman who presented with a 1-year history of a right medial canthal mass and bloody tears and who was found to have a lacrimal sac melanoma is reported. A literature search revealed that only 16 cases of primary lacrimal sac melanoma have been reported. Current therapeutic modalities are discussed.

Orbital varices: a surgical approach.

Abstract Five cases of orbital varices are presented, demonstrating a surgical approach with the use of vascular clips. Three of four cases were clipped at the apex of the orbit, with no recurrence. A fourth case was clipped two-thirds of the way back in the orbit, with no progression of the varix and significant improvement of the patients symptoms. A fifth case failed because of extensive hemorrhaging. Follow-up ranged from 2 to 9 years.