Michael A. Burnstine

Clinical recommendations for repair of orbital facial fractures.

Purpose of review Orbital facial fractures are a common result of facial trauma. Enophthalmos, diplopia resulting from extraocular muscle dysfunction, and infraorbital nerve hypesthesia may occur. The indications and timing for fracture repair are debated. Recent findings The timing and treatment indications for orbital facial fractures are evolving. For orbital floor fractures, nonresolving oculocardiac reflex, the “white-eyed” blowout fracture, and early enophthalmos or hypoglobus are indications for immediate surgical repair. Surgery within 2 weeks is recommended in cases of symptomatic diplopia with positive forced ductions and evidence of orbital soft tissue entrapment on computed tomography examination or large orbital floor fractures, which may cause latent enophthalmos or hypo-ophthalmos. For midfacial, lateral, supraorbital, medial wall, and nasoethmoidal fractures, repair within 2 weeks is indicated to avoid difficult repair from immediate posttraumatic wound healing. Summary Orbital facial fracture management is germane to ophthalmologists, plastic surgeons, otolaryngologists, and others who treat patients.

Docetaxel-induced histologic changes in the lacrimal sac and the nasal mucosa

Purpose To identify histopathologic changes in the lacrimal sac and the nasal mucosa caused by docetaxel in 3 patients with canalicular narrowing and nasolacrimal duct obstruction. Methods Small case series. Lacrimal sac and nasal mucosal specimens were obtained at the time of dacryocystorhinostomy or during silicone intubation to correct epiphora in 3 patients receiving docetaxel. Histologic evaluation was performed. Results Extensive fibrotic changes in the stroma of the lacrimal sac and the nasal mucosa were the prominent histologic features in all 3 patients. A biopsy specimen was taken from the lower portion of the nasal mucosa (near the inferior turbinate) in one patient at the time of silicone intubation and showed both clinical and histologic evidence of keratinization with marked epidermalization of the surface epithelium, thickening, and parakeratosis of the squamous epithelium. Conclusions Nasolacrimal duct obstruction secondary to treatment with docetaxel may be in part due to stromal fibrosis in the mucosal lining of the lacrimal drainage apparatus.

Rhabdomyomatous mesenchymal hamartoma of the eyelid: report of a case and literature review.

PURPOSE To report a rare case of rhabdomyomatous mesenchymal hamartoma and to compare its features with those cases previously reported. DESIGN Interventional case report and literature review. INTERVENTION Complete ophthalmologic and systemic examinations followed by excisional biopsy and histopathologic examination. MAIN OUTCOME MEASURES Clinical examination features and histopathologic findings. RESULTS A 6-month-old Latino male presented with a congenital, elevated, smooth, flesh-colored right lower eyelid lesion. An ipsilateral right limbal dermoid and an upper eyelid coloboma were also present. Excisional biopsy of the eyelid lesion revealed randomly oriented mature striated muscle tissue with associated adipose tissue, blood vessels, pilosebaceous units, and peripheral nerves, findings consistent with rhabdomyomatous mesenchymal hamartoma. Of the 24 reported cases (including the current case), eight had associated congenital anomalies. CONCLUSIONS Although rhabdomyomatous mesenchymal hamartomas are rare and benign, they may be associated with other congenital anomalies and anomaly syndromes. As a result, we recommend systemic evaluation of patients diagnosed with this entity.

Migration of intraocular silicone oil into the subconjunctival space and orbit through an ahmed glaucoma valve

PURPOSE To report a patient with intraocular silicone oil migration into the subconjunctival space and orbit through an Ahmed glaucoma valve implant. METHODS Observational case report. A 29-year-old female with diabetes mellitus and proliferative diabetic retinopathy underwent three left eye pars plana vitrectomies and ultimately intraocular silicone oil placement for tractional retinal detachment. Subsequently, she developed neovascular glaucoma and underwent an inferotemporal Ahmed glaucoma tube implant, left eye. RESULTS Intraocular silicone oil migrated through the Ahmed glaucoma valve into the subconjunctival space and orbit. Left eye evisceration with silicone oil removal was performed for a blind painful left eye and improvement of appearance. CONCLUSION Silicone oil migration through an Ahmed valve may be observed after retinal detachment repair with intraocular silicone oil. An Ahmed valve may be contraindicated in eyes of patients with intraocular silicone oil.

REGRESSION OF KAYSER-FLEISCHER RINGS DURING ORAL ZINC THERAPY : CORRELATION WITH SYSTEMIC MANIFESTATIONS OF WILSON'S DISEASE

Fourteen patients presenting with neuropsychiatric manifestations of Wilsons disease were treated with oral tetrathiomolybdate (TM) for 8 weeks followed by oral zinc (Zn) maintenance therapy. The patients were evaluated prospectively at baseline and at yearly intervals for up to 5 years by slit-lamp biomicroscopy and photography, quantitative neurologic and speech pathology examinations, 24-h urine copper collection, and a quantitative scoring of magnetic resonance imaging (MRI) of the brain. Kayser-Fleischer (KF) ring size decreased significantly during the 5-year study period (p < 0.0001). Although results of neurologic examination, speech pathology examination, and 24-h urine copper level analysis in symptomatic Wilsons disease patients improved during the study period, KF ring regression did not correlate with the improvement in these clinical parameters (p > 0.05). However, there was a correlation between MRI scores and KF ring regression (p = 0.02). Anticopper therapy with TM followed by zinc maintenance therapy is a safe and effective treatment for patients with neurologically symptomatic Wilsons disease. This treatment leads to reduction in KF ring size; however, KF ring reduction is not a good predictor of clinical improvement for patients with neuropsychiatric manifestations of Wilsons disease.

Upper blepharoplasty: A novel approach to improving progressive myopathic blepharoptosis

OBJECTIVE To describe the results of upper blepharoplasty for the treatment of progressive myopathic upper eyelid blepharoptosis. DESIGN Retrospective, noncomparative case series. PARTICIPANTS Six consecutive patients treated bilaterally. INTERVENTION Upper blepharoplasty in 6 patients (12 eyelids) with progressive myopathic ptosis. MAIN OUTCOME MEASURES Subjective visual improvement, ocular comfort, preoperative and postoperative margin reflex distances, lagophthalmos, and degree of corneal keratopathy at last follow-up date. RESULTS All patients had subjective visual improvement and denied ocular discomfort. Upper eyelid ptosis, measured by margin reflex distances, was improved. No worsening of lagophthalmos or corneal keratopathy was noted. CONCLUSIONS Upper blepharoplasty may be an excellent alternative for ptosis treatment in patients with progressive myopathies. Improvement in ptosis, margin reflex distance, without concomitant lagophthalmos, and corneal keratopathy can be achieved.

Orbitotemporal Neurofibromatosis: Classification and Treatment ∗

Purpose: To review the clinical findings in orbitotemporal neurofibromatosis and discuss treatment options. Clinical features, histopathologic characteristics, and treatment options are reviewed. Methods: A Medline literature search from 1966 to 2004 was performed, using the key words: orbitotemporal neurofibromatosis, orbitopalpebral neurofibromatosis, orbitofacial neurofibromatosis, cranio-orbital neurofibromatosis, and cranio-orbital-temporal neurofibromatosis, and the pertinent literature was reviewed. Additionally, our experience with two patients is reported. The surgical procedures are discussed. Conclusion: The management of orbitotemporal neurofibromatosis is challenging. The planned surgical approach and extent of resection depend on the severity of the orbital soft tissue and bony involvement and on the visual potential. Ultimately, orbital exenteration may be needed for rehabilitation and cosmesis.

ANTERIOR ISCHEMIC OPTIC NEUROPATHY FOLLOWING NECK DISSECTION

Ischemic optic neuropathy (ION) is a rare but devastating complication of surgery. It has traditionally been associated with intraoperative hypotension in patients with underlying arteriosclerosis.

Squamous metaplasia of the canaliculi associated with 5-fluorouracil: A clinicopathologic case report

OBJECTIVE To illustrate a newly recognized histopathologic change in a patient with canalicular obstruction after weekly administration of 5-fluorouracil for colon cancer. DESIGN Interventional case report. METHODS A full-thickness section of canaliculus was obtained during surgical repair. MAIN OUTCOME MEASURE Histopathologic changes in the specimen. RESULTS The prominent histologic feature of the canalicular specimen was severe squamous metaplasia with narrowing of the lumen. CONCLUSION Canalicular obstruction may follow systemic use of 5-fluorouracil due to squamous metaplasia.

Wilson's disease: Presymptomatic patients and Kayser-Fleischer rings

PURPOSE We evaluated patients with Wilsons disease to determine (1) whether presymptomatic patients who have Kayser-Fleischer (K F) rings demonstrate a more significant alteration of copper metabolism than those who do not have K F rings, and (2) whether presymptomatic patients have smaller K F rings than symptomatic Wilsons disease patients. METHODS Thirty-two patients with presymptomatic Wilsons disease were retrospectively analyzed. Sixteen of these had received no prior anti-copper therapy and underwent testing for baseline copper metabolism (24-hour urine copper, liver copper, and plasma ceruloplasmin). Quantitative measurements of K F rings were made for the group of untreated presymptomatic patients and a control group of symptomatic Wilsons disease patients. RESULTS We hypothesized that the 24-hour urine copper, in particular, would correlate with the presence of a K F ring. However, no significant difference was found between any of the baseline copper variables for presymptomatic patients who had K F rings compared to those who did not. K F rings of presymptomatic patients were found to be significantly smaller than K F rings of patients with symptomatic Wilsons disease (p < 0.05). CONCLUSIONS While this study does not show any relationship between urinary copper excretion and the presence of K F rings, it suggests that the larger K F ring size correlates with Wilsons disease severity.