Milap P. Mehta

Orbital Xanthogranuloma in an Adult Patient With Xanthelasma Palpebrarum and Hypercholesterolemia

A 44-year-old man with a history of hypercholesterolemia presented with eyelid lesions and a separate orbital mass. Pathology of eyelid lesions confirmed xanthelasma palpebrarum, and pathology of the orbital mass showed a non-Langerhans cell xanthogranuloma, consistent with a lesion within the spectrum of adult orbital xanthogranulomatous disorders. While xanthelasma palpebrarum is associated with increased serum lipids, adult orbital xanthogranuloma does not share a clear association. Distinct, histology-proven xanthelasma palpebrarum and orbital xanthogranuloma rarely occur together in the literature. This case further represents a unique coexistence between these 2 lesions in an adult with hypercholesterolemia.

Internal Cantholysis for Repair of Moderate and Large Full-Thickness Eyelid Defects

PURPOSE To determine the safety and efficacy of internal cantholysis for closure of larger full-thickness eyelid defects. DESIGN Retrospective review of a consecutive case series. PARTICIPANTS Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. METHODS Retrospective review of a consecutive case series of all patients undergoing transconjunctival lateral cantholysis for repair of moderate and large full-thickness eyelid defects between October 2008 and November 2010. Moderate was defined as ≥ 14 mm in horizontal length, and large was defined as ≥ 20 mm in horizontal length. MAIN OUTCOME MEASURES Charts were reviewed for patient demographics; indication for surgery; defect size, type, and location; other concomitant repair; follow-up interval; and complications. RESULTS Eighteen patients (18 eyelids) underwent internal cantholysis for repair of a moderate or large full-thickness eyelid defect during the study period. Average patient age was 73 years (range, 45-94 years), and there were 10 male and 8 female patients. Average defect size was 19.0 mm (range, 14-25 mm). Average follow-up interval was 4.6 months (range, 1-12 months). Complications included eyelid margin notch (3 cases), persistent canthal dystopia (3 cases), trichiasis (2 cases), pyogenic granuloma (2 cases), eyelid margin nodule (1 case), lower eyelid elevation of 1 mm (1 case), and mild resolving medial lagophthalmos (1 case). No patient requested or required further surgery on the operated eyelid for any reason during the study period. CONCLUSIONS Internal cantholysis allows for closure of moderate and large full-thickness eyelid defects. Complications are acceptable in light of the morbidity of other therapeutic options, such as semicircular flap or shared eyelid flap procedures.

Medial Orbital Wall Landmarks in Three Different North American Populations

Abstract Purpose: We sought to measure the medial orbital wall foramina distances in two previously unstudied populations, to describe a new bony medial wall feature, and to validate the accuracy of a new coordinate measurement device within the orbit. Methods: Dried, well-preserved, complete human skulls without orbital defects were studied. Age, gender, birthplace, ethnicity, and laterality of the orbit were recorded for each skull. Supranumerary ethmoidal foramina were recorded, and the fronto-ethmoidal groove depth was measured. The distances between the anterior lacrimal crest (ALC) – anterior ethmoidal foramen (AEF), AEF – posterior ethmoidal foramen (PEF), and PEF – optic canal (OC) were measured first by surgical ruler and wire and then by the Microscribe coordinate measurement device. Results: One hundred and forty-six orbits were studied. Fifty-seven orbits were of European or Caucasian descent, 68 orbits of African American descent, 2 orbits of West African descent, 11 orbits of Eskimo descent, and 8 orbits of unknown origin. No significant differences existed between the manual and Microscribe measurements for the ALC-AEF, AEF-PEF, and PEF-OF distances (p < 0.0001). A significant frontoethmoidal groove was observed in 27/146 (19%) orbits, in 6/57 (11%) Caucasian orbits, in 17/70 (24%) African American orbits, and in 4/11 (36%) Eskimo orbits. Supranumerary ethmoidal foramina were found in 50/146 orbits (34.2%) and in 17/27 (63%) orbits with a significant frontoethmoidal grooves. Conclusions: No significant differences in medial wall foramina distances exist between African American and Caucasian orbits; however, a frontoethmoidal groove occurs more commonly in African American orbits. This groove often occurs in the presence of supernumerary ethmoidal foramina. The Microscribe coordinate measurement system represents a valid tool to measure distances within the orbit.

Predictability of Optic Foramen Location From a Ray Through the Ethmoidal Foramina.

Purpose: To determine how accurately a ray through the anterior and posterior ethmoidal foramina predicts the location of the optic foramen. Methods: Dried, well-preserved, complete human skulls without bony defects belonging to the Hamann-Todd osteological collection of the Cleveland Museum of Natural History were examined. Photography was performed and a ray was drawn on orbit photographs extending through the center of the anterior and posterior ethmoidal foramina toward the optic canal. The location of the ray at the anterior aspect of the optic canal was recorded. Results: Sixty-six total orbits were examined from 36 skulls with 6 skulls with only unilateral data. Thirty-eight orbits were of African descent and 28 were of European descent with an average age 45.25 years (range = 19–89 years). The anterior–posterior ethmoidal foramen ray extended superior (12/66), through (53/66), and inferior (1/66) to the optic canal. Of those rays passing through the optic canal, 32/53 (60%) passed through the upper one-third, 19/53 (36%) passed through the middle one-third, and 2/53 (4%) passed through the lower one-third of the optic canal. Conclusions: The anterior–posterior ethmoidal foramen ray highly predicts the superior aspect of the optic canal. This information can guide medial orbital wall surgery.

Conjunctival bleeding after ectropion repair due to paraneoplastic primary fibrinolysis.

In addition to predisposing a patient to hypercoaguability and thrombosis, cancers may also cause an antithetical bleeding diathesis through primary fibrinolysis. This paraneoplastic pathology has been documented and studied in prostate cancer patients for nearly a century but is under-recognized as a possible complication of surgery. We report a case of primary fibrinolysis after elective ectropion repair in a patient with prostate cancer. Here paraneoplastic fibrinolysis produced a delayed postoperative hemorrhage requiring specialized therapies, including hospitalization for transfusions of fresh frozen plasma and inhibitors of fibrinolysis. Even in the case of an ambulatory and stable cancer patient, awareness of this complication and its management can help guide surgical decision-making and improve outcomes and follow-up care.