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Purpose: To investigate the social implications of blepharoptosis and dermatochalasis., Methods: Two hundred ten individuals rated whole-face photographs of a series of patients based on 11 different personal characteristics: intelligence, threat, friendliness, health, trustworthiness, hard work, mental illness, financial success, attractiveness, alcoholism, and happiness. Preoperative and postoperative photographs of both male and female patients with bilateral blepharoptosis and/or dematochalasis were used. The paired t test was used to compare preoperative versus postoperative ratings on the 11 characteristics., Results: The preoperative photographs were rated more negatively than were the postoperative photographs (p < 0.01) on all 11 characteristics for both male and female patients by the 210 study subjects., Conclusions: Members of our society view individuals with blepharoptosis and dermatochalasis negatively. These social attitudes may lead to unjust bias toward affected patients, and surgical correction probably provides benefits beyond improved visual function.

Purpose: The purpose of this study was to investigate the two accepted mechanisms of the orbital blowout fracture (the hydraulic and the buckling theories) from a clinical, experimental, and theoretical standpoint., Methods: Clinical cases in which blowout fractures resulted from both a pure hydraulic mechanism and a pure buckling mechanism are presented. Twenty-one intact orbital floors were obtained from human cadavers. A metal rod was dropped, experimentally, onto each specimen until a fracture was produced, and the energy required in each instance was calculated. A biomathematical model of the human bony orbit, depicted as a thin-walled truncated conical shell, was devised. Two previously published (by the National Aeronautics and Space Administration) theoretical structural engineering formulas for the fracture of thin-walled truncated conical shells were used to predict the energy required to fracture the bone of the orbital floor via the hydraulic and buckling mechanisms., Results: Experimentally, the mean energy required to fracture the bone of the human cadaver orbital floor directly was 78 millijoules (mJ) (range, 29-127 mJ). Using the engineering formula for the hydraulic theory, the predicted theoretical energy is 71 mJ (range, 38-120 mJ); for the buckling theory, the predicted theoretical energy is 68 mJ (range, 40-106 mJ)., Conclusion: Through this study, we have experimentally determined the amount of energy required to fracture the bone of the human orbital floor directly and have provided support for each mechanism of the orbital blowout fracture from a clinical and theoretical basis.

Purpose: To illustrate the utility of gallium scintigraphy in the diagnosis and management of orbital lymphoma., Methods: A patient with an orbital lymphoma is reported. The results of the computed tomography scan and gallium scan are reviewed., Results: Although the orbital lymphoma was readily visible on the gallium scan, it was poorly visualized on the computed tomography scan, which was interpreted as normal., Conclusion: Gallium scanning is a valuable adjunct in the diagnosis and management of orbital and systemic lymphoma.

Purpose: To describe the clinical features of patients with unusual orbital foreign bodies., Methods: The clinical histories, preoperative photographs, imaging studies, and surgical pathologic findings of five patients with unusual orbital foreign bodies are presented. Additionally, published reports pertaining to similar cases were reviewed., Results: The five patients treated by the authors had good outcomes., Conclusions: An orbital foreign body may be overlooked because a small penetrating wound may be accompanied by minimal or no signs of inflammation early in the clinical course. A careful history and physical examination, imaging studies, and a strong suspicion are helpful for establishing the diagnosis of an orbital foreign body.

Lacrimal ultrasonography (echography) evaluates lesions in that drainage system in a painless, noninvasive way in the office. The technique complements other imaging methods and can be correlated with histological results. The authors survey the principles and technique and describe the normal ultrasound, indications, applications, and limitations. Lacrimal ultrasound, whose potential has just lately been recognized, only reveals gross anatomic abnormalities and cannot evaluate the functional integrity of the lacrimal excretory system.

Traumatic eyelid avulsion is reported infrequently. We cared for an 18-year-old man who lost > 75% of his right upper eyelid. The tissue was recovered 10 h following the initial trauma. Successful surgical reimplantation resulted in a functional upper eyelid with extensive madarosis. An experimental study was undertaken to attempt to determine the optimal method for preservation of avulsed eyelid tissue. Experimental surgery was performed to simulate repair of eyelid avulsion. The postoperative changes in experimentally reimplanted eyelids parallel those noted in the clinical example of eyelid avulsion. This clinical example and experimental study suggested the following management principles for handling avulsed eyelid tissue: eyelid tissues should not be immersed in saline; avulsed eyelid tissues should be stored at 4 degrees C; if reimplantation time is < 6 h, storage in a cold moist environment is adequate.

A patient with hereditary hemorrhagic telangiectasia and bloody tears is described. This case report serves to familiarize the ophthalmic plastic and reconstructive surgeon with the differential diagnosis of bloody tears. Conjunctival, oral mucosal and cutaneous findings are documented, and the systemic and ocular manifestations of hereditary hemorrhagic telangiectasia are discussed.

A 48-year-old woman with mild Graves' orbitopathy underwent bilateral lateral orbital decompressions through preauricular hairline incisions by a general plastic surgeon. Immediately postoperatively she developed marked left orbital and eyelid edema and incapacitating diplopia due to a large angle esotropia and severe bilateral abduction deficits. Examination 13 months later revealed normal visual acuities and a 90 prism diopter esotropia. She underwent complex strabismus surgery with resultant orthophoria in primary and down gaze. Four years later, a thin section computed tomographic scan revealed severe attenuation of both lateral rectus muscles with incarceration of the muscle bellies into the lateral osteotomy sites. This case demonstrates a rare, but avoidable, complication of orbital surgery for Graves' disease.

There are many reviews of pediatric orbital tumors in the literature. Most of the series originated from the tumor registries of large pathology referral centers, whereas others are from large medical institutions and pediatric hospitals. The distribution of types of tumors reported in each series are unavoidably biased by the nature of the evaluating facility. The findings were also affected by the geographic location of the clinical facility. We present an analysis of 141 orbital tumors in children and review 9 other series (totaling 1,229 cases) for an aggregate total of 1,370 cases. Our clinically based series had an incidence of malignant lesions of 10.6%, much lower than the 24% incidence among the combined referral center/pediatric hospital studies. Cystic orbital and vasculogenic tumors were the most common, comprising 58% of our cases and 40% of orbital tumors in children among the combined series.

The use of Tensilon (edrophonium chloride) is important in the diagnostic evaluation of many ptosis patients. A three-way stopcock with double syringe allows concomitant administration of atropine to counteract the cholinergic side effects of edrophonium.

In humans, a variety of immunodeficiency states have been recognized whereby infectious agents gain access to the body and produce disease. The orbit may become involved following injury or surgery, through spread of infection from surrounding structures, or by metastatic seeding from a distant source. Orbital infections associated with immunodeficiency represent a special problem in diagnosis and management for the ophthalmologist. Twenty-four patients with immunodeficiency-associated orbital infections who illustrate a wide range of factors associated with immunodeficiency, agents that produce infection, ophthalmic signs that result, and effects of antimicrobial therapy are presented.