Peter A. Martin

Orbital metastasis from transitional cell carcinoma of the bladder.

Transitional cell carcinoma (TCC) is a common bladder tumour, 10−15% of which will exhibit invasive behaviour. About 50% of patients with invasive TCC will eventually develop distant metastases, usually to lymph nodes, lung or bones. The case is reported of bladder TCC metastasizing to the orbit.

External Dacryocystorhinostomy: Assessing Factors that Influence Outcome

Purpose: To present the experience of external dacryocystorhinostomy (DCR) at a tertiary referral center and investigate factors that may affect clinical outcomes. Methods: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to patient demographics, preoperative assessment, operative details, surgical technique, postoperative management, and clinical outcomes. This information was then analyzed, with emphasis on factors that influence surgical outcomes and success. Results: A total of 338 cases were reviewed. The mean age at time of surgery was 64.82 years and the majority of patients were female (65%). Epiphora was the major preoperative symptom. Assisted local anesthesia and day stay surgery were the most common surgical settings. There was a statistically significant difference in theatre time between consultant and trainee surgeons (P < 0.00001). The mean final follow-up time was 11 months. Overall, 77.3% of patients had full resolution of symptoms and 20.8% had partial resolution. Only five patients (1.9%) had no resolution of symptoms. There was no significant difference in outcomes between consultants and trainees. Patients with anatomical nasolacrimal obstruction had significantly better outcomes compared with functional obstruction (P = 0.04). The postoperative fluorescein dye disappearance test was a good predictor of clinical success (P = 0.005). Silicone intubation for greater than 6 months was associated with better outcomes (P = 0.002). Conclusions: The results at our tertiary center are comparable to results stated in the literature. In our series, only the amount of nasolacrimal obstruction and duration of postoperative intubation influenced surgical success.

Bisphosphonate-Induced Orbital Inflammation: A Case Series and Review.

Abstract Introduction: To present a series of patients with bisphosphonate induced orbital inflammation, and to review the clinical presentation, radiological features, treatment options and outcomes. Methods: We present a multicentre, retrospective case series review of patients with a clinico-radiological diagnosis of bisphosphonate induced orbital inflammation and review all the reported cases of this complication in the literature. Results: Four new patients with bisphosphonate induced orbital inflammation were added to the 25 cases in the literature. Intravenous zoledronate was the commonest precipitant (22/29, 75.9%) and inflammation occurred 1–28 (mean 3) days post-infusion. Orbital imaging identified orbital inflammation in 22/29 cases and extra-ocular muscle enlargement in 8/29. Five patients presented with reduced vision of which one – with anterior ischaemic optic neuropathy – did not resolve. The vision resolved in all except one patient, with most requiring steroid treatment. Conclusions: Bisphosphonates have a pro-inflammatory effect, which can precipitate orbital inflammation. This rare, but potentially serious complication of bisphosphonate treatment should be considered by clinicians using bisphosphonate treatment and by ophthalmologists seeing patients with orbital inflammatory disease.

The lateral triangle flap--a new approach for lateral orbitotomy.

Lateral orbitotomy with or without removal of the lateral wall enables access to the extraconal and intraconal spaces of the orbit lateral to the optic nerve. We present the lateral triangle flap technique using an upper eyelid skin crease incision and skin incision from the lateral canthal angle joining together laterally at the outer margin of the lateral orbital rim, just beyond the lateral orbital margin. A triangular skin muscle flap is raised medially, based at the canthal angle, providing maximal exposure of the lateral and superolateral orbital wall. The deep lateral orbital wall can be burred away for lateral orbital decompression, or a bone flap removed for exposure of deep intraconal or extraconal lesions. The lateral triangle flap provides excellent exposure and postoperative cosmetic results.

The Role of Mucosal Flaps in External Dacryocystorhinostomy

Purpose: To determine whether a mucosal anastomosis fashioned at the time of external dacryocystorhinostomy (DCR) influences postoperative outcome. Methods: The clinical records of all patients who underwent external DCR at Sydney Eye Hospital between May 2000 and August 2007 were reviewed. Data were collected in regards to surgical technique, clinical outcomes and postoperative management. Chi-square statistical analysis was done to determine the significance of the different flap techniques on surgical success. Results: A total of 260 medical records were reviewed. The main outcome measure was postoperative resolution of symptoms. The mean final follow-up time was 11 months. There was no statistically significant difference in outcome between patients who had both anterior and posterior flaps sutured, compared to those who had anterior flap sutures only (73% vs 79%, p = 0.51). Patients who had no sutured flaps had an overall success rate of 89% compared to those that had at least the anterior flaps sutured together (76%); this difference was not significant (p = 0.45). Conclusion: There was no statistical difference in symptom outcome between patients in whom both mucosal flaps were sutured, those who had only the anterior flap sutured, or those who did not have either flap sutured at the time of surgery.

Lymphomatoid Papulosis Type C of the Eyelid in a Young Girl: A Case Report and Review of Literature

Abstract Purpose: To report an unusual presentation of a case of Lymphomatoid papulosis(LyP) in a young girl. Material and Methods: A 14-year-old female presented with a history of swelling of the left upper eyelid of two weeks duration. There was a history of trivial trauma prior to the swelling. The patient was diagnosed as having pre-septal cellulitis elsewhere and was put on oral antibiotics. The lesion was non-responsive to oral antibiotics. The patient was then referred to our hospital. Ocular examination revealed an elevated lesion measuring 15 mm × 10 mm on the left upper eyelid, associated with pre-septal swelling and induration. Ocular movements were normal. The anterior and posterior segment examination was normal. Incision biopsy was done from the eyelid lesion. Multiple cutaneous lesions were also biopsied. Results: The histopathology examination confirmed the diagnosis of lymphomatoid papulosis type C. Dermatological and systemic evaluation ruled out the other aggressive forms of CD30(+) lymphoid proliferation. Conclusion: We report an unusual presentation of lymphomatoid papulosis(LyP) type C in a young girl. Complete systemic work up and histopathological evaluation is mandatory in cases of suspicious lesions, not responding to conservative treatment.

Orbital Gastrointestinal Stromal Tumor Metastasis

Purpose: To report an uncommon case of orbital gastrointestinal stromal tumor (GIST) metastasis. Material and Methods: Observational case report. Results: A 65-year-old woman with metastatic GIST involving the left orbit with a history of two separate GIST nodules involving the stomach 6 years earlier. Computed tomography (CT) scan demonstrated a well-circumscribed enhancing lesion confined to the anterior orbit. Histopathology analysis of the tumor showed predominantly spindle cells with focal epithelioid forms. It also stained positive for c-KIT (CD117) on immunochemistry, confirming the diagnosis. Additional medical treatment was not required, and the patient was followed up regularly for disease recurrence. Conclusion: GISTs typically occur as sporadic solitary tumors. In malignant cases, it usually metastasizes to the liver or other intraabdominal sites. Orbital involvement is extremely rare. This is the first case of metastatic GIST involving the anterior orbit with histopathological and immunochemical confirmation.

Unusual presentation of metastatic neuroendocrine (carcinoid) tumor in the orbit

Purpose: To report a rare presentation of metastatic neuroendocrine tumor in the orbit. Case report: A 43-year-old female presented with a left painful proptosis of 4 days duration associated with nausea and vomiting. There was a history of multiple liver metastases from an unknown primary carcinoid tumor for 7 years. Ocular examination revealed severe eyelid swelling associated with conjunctival injection, chemosis and complete external ophthalmoplegia. The visual acuity was 20/20 in right eye and no light perception in left eye. The initial clinical diagnosis was orbital cellulitis with optic nerve compression. Orbital imaging showed gross enlargement of left lateral rectus muscle with optic nerve compression consistent with a carcinoid metastasis. Surgical resection of the tumor mass along with the involved muscle was performed. Histopathology confirmed the diagnosis of neuroendocrine (carcinoid) tumor infiltrating fibro fatty tissue and skeletal muscle with widespread necrosis. On Immunohistochemical staining the tumor cells were positive for chromogranin A, synaptophysin and cytokeratin. Post-operative external beam radiotherapy (EBRT) and systemic chemotherapy were given. Conclusion: Acute necrosis in metastatic orbital carcinoid tumor can lead to orbital inflammation which could mimic orbital cellulitis. Systemic history and orbital imaging play an important role in differentiating the infective etiology from metastasis.

Recurrent lacrimal sac rhinosporidiosis involving the periocular subcutaneous tissues, nasolacrimal duct and nasopharynx.

Rhinosporidiosis is a chronic infection caused by the organism Rhinosporidium seeberi. It is endemic in parts of southern India and Sri Lanka, but rarely seen outside these areas. The infection predominantly affects the nasal mucosa; however, it can also affect the ocular surface and adnexa. We present a case of rhinosporidiosis initially involving the lacrimal sac, with recurrence in the periocular subcutaneous tissues, nasolacrimal duct and nasopharynx.