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Mascara, a widely used cosmetic, is associated with eye pathology. The authors report 3 cases of eye problems secondary to long-term mascara use. Two patients had multiple pigmented conjunctival lesions; one of these had a history of melanoma of the hand. Conjunctival biopsy revealed nonmelanocytic pigment granules within conjunctival stroma cells in both cases. The other patient had a history of dry eye, and also showed pigment clumping around a punctal plug. The third patient had canalicular obstruction from a mascara-laden dacryolith ("dacryomascaralith"), the first such case reported. A literature review revealed cases of eyelid dermatitis, infectious keratitis, a conjunctival mass ("mascaroma"), and others. Ophthalmologists should be aware of mascara's associated eye problems. The physical findings combined with a high index of suspicion, especially in cases of heavy mascara use, may allow for an accurate diagnosis and spare the patient an otherwise unnecessary invasive procedure.

Purpose To report cases of Horner syndrome caused by interventions in the neck region. Methods Retrospective chart review and focused literature search. Results Six cases of Horner syndrome caused by neck procedures were identified. The study included 5 women and 1 man, ranging in age from 37 to 79 years old. Procedures included coronary artery bypass surgery with neck catheter, carotid endarterectomy, cervical and thoracic sympathectomy, parathyroid surgery, and 2 cases of cervical spine fusion surgery. Conclusions Physicians should be aware that procedures involving the neck, even relatively minor ones, may be a cause of Horner syndrome. In the evaluation of patients with newly diagnosed Horner syndrome, it is important to obtain the history of prior surgeries or procedures involving the neck that may identify a cause of sympathetic denervation and etiology of Horner syndrome.

Objective To detail the characteristics and management of rarely reported and incompletely described dermoid cysts originating in the temporal fossa. Design Retrospective case series. Participants Five patients ranging from 2 to 38 years of age with a mass in the temporal region (posterior to the lateral orbital rim) participated. Intervention Computed tomography (CT) and excisional biopsy were performed. Main outcome measures Clinical and CT characteristics and surgical outcomes were measured. Results Computed tomography showed cystic lesions, originating from the region anterior to the confluence of the greater wing of the sphenoid, frontal, and zygomatic bones. Displacement of the anteriormost portion of the temporalis muscle was common. Three cysts were isolated to the temporalis fossa, while two showed more extensive bony erosion and extension into the cranial and orbit cavities. At surgical excision, gross rupture of the cysts was noted in two cases, and two were completely liquefied. Histopathology showed variable inflammation surrounding all of the dermoid cysts. All patients did well after surgery. Conclusions Dermoid cysts may infrequently occur “primarily” in the temporal fossa. Bone involvement and anterior temporalis muscle displacement are common. An origin from the area anterior to the confluence of the greater wing of the sphenoid, frontal, and zygomatic bones is seen. A coronal approach facilitates wide exposure and excision. When dural extension is suggested on CT, neurosurgical assistance may be required.

A 71-year-old white woman sought treatment for poroma of the right lower eyelid. Excisional biopsy was performed, and the specimen had histologic features consistent with poroma. One year after excision, there has been no recurrence of the lesion. Clinicians should be aware that poroma can occur in regions other than the hands and feet.

This report details the gross and histopathologic findings of an unusual complex choristoma at the lateral canthus. Although this lesion displays elements of hair follicle nevus, bulbar dermoid, epibulbar osseous choristoma, and accessory tragus, it does not fit neatly in any of these categories. We propose that this lesion is the result of faulty migration of pluripotential cells during embryogenesis.

Chronic cicatrizing conjunctivitis is a relatively uncommon condition resulting in significant ophthalmic morbidity, including keratoconjunctivitis sicca, cicatricial entropion, trichiasis, corneal scarring, significant discomfort, and visual loss. The potential causes of cicatrizing conjunctivitis are varied and include commonly encountered entities such as ocular cicatricial pemphigoid, Stevens-Johnson syndrome, and trachoma and many more rare causes which are particularly difficult to diagnose and treat and may not be familiar to the ophthalmologist. The authors herein present a case of chronic cicatrizing conjunctivitis, cicatricial entropion, and trichiasis caused by a rare entity called linear IgA bullous dermatosis. The case presentation conforms to the tenets of the Declaration of Helsinki and is Health Insurance Portability and Accountability Act compliant. This chronic dermatosis has a varied presentation, and the ophthalmic manifestations in particular have been infrequently described. This case demonstrates the benefits of immunohistochemistry in diagnosis and the difficulties in medical and surgical management of linear IgA bullous dermatosis while underscoring the lifelong difficulties in managing chronic inflammatory conditions causing ocular cicatrization.

Herein we present a retrospective case report of a very rare fibrolipoma originating in the orbit. Lipomas and related variants presenting in the orbit are very rare. Only 2 documented orbital fibrolipomas were noted in our review of literature. A 26-year-old woman presented with a growing mass below the left eyebrow 4 years after suffering facial trauma after being kicked in the face by a horse. CT demonstrated a hypodense nodule adherent to the orbital portion of the left frontal bone that was not encapsulated. An elective left anterior orbitotomy with excisional biopsy was performed, and fibrolipoma was confirmed on histopathologic examination. There was no evidence of tumor after 2-year follow up. The presence of a fibrolipoma in the periosteum of the orbital rim is very rare and might be a result of inflammatory transformation following facial trauma.

Purpose: Variations in physician practice patterns, particularly with reference to cost-intensive resource utilization, are increasingly being scrutinized. However, little information is currently available regarding physician practice patterns for oculoplastic surgery. Methods: The authors surveyed members of the American Society of Ophthalmic Plastic and Reconstructive Surgery regarding their most common site of service, type of anesthesia, and first postoperative week of follow-up for 15 selected eyelid, lacrimal, and orbital procedures. Results: The majority of eyelid and lacrimal surgeries are currently performed on an out-patient basis (hospital out-patient, ambulatory surgery center, or office}, typically using local anesthesia, with or without sedation. Regional differences were noted. Physicians in western states showed a greater tendency toward office-based surgery for procedures such as blepharoplasty and ptosis repair. Orbital procedures were performed more frequently as a hospital inpatient surgery, under general anesthesia. Patterns of follow-up within the first postoperative week varied considerably for most procedures. Compared with admitting practices in 1987, an obvious trend toward out-patient surgery was noted. Conclusion: Variations in practice patterns will assume greater importance as the pressure for cost-containment increases. Total costs are affected by physician choices for site of service and type of anesthesia. This study allows surgeons who perform oculoplastic procedures to compare their practices with a national group specializing in such surgery. Further outcome-oriented studies are needed to develop practice guidelines for "preferred patterns" of care.

Purpose To evaluate a procedure to prevent lower eyelid retraction, which may occur after inferior rectus muscle recession surgery as a direct consequence of the intimate anatomic connections between the inferior rectus muscle and lower eyelid retractors. Methods We evaluated the technique of primary infratarsal lower eyelid retractor lysis on 12 eyelids of ten patients undergoing inferior rectus muscle recession of 3 mm or more. Indications for surgery included restrictive strabismus related to Graves' ophthalmopathy, orbital blowout fracture, and orbital fibrosis syndrome. Results For the 12 eyes, inferior rectus muscle recession ranged from 3 to 10 mm (mean, 5.3 mm). Postoperatively there was no significant change in mean lower eyelid position (P > .82), and no patient developed inferior scierai show. Conclusion Primary infratarsal eyelid retractor lysis is an effective technique for preventing lower eyelid retraction after inferior rectus muscle recession strabismus surgery.

Purpose: To prospectively examine the change in upper eyelid position on downgaze in patients with blepharoptosis. Methods: Upper eyelid margin to corneal light reflex distance (uMRD) was measured in primary gaze and in 30° to 40° downgaze in 50 consecutive patients with acquired ptosis and 10 consecutive patients with congenital ptosis. Results: For the acquired ptosis group, the mean change in uMRD on downgaze was −0.8 mm (range, −2.5 to 1.0 mm), with one patient (2%) showing an increase, 10 (20%) no change, and 39 (78%) a decrease in upper eyelid position. For the congenital group, the mean change in uMRD on downgaze was +2.1 mm (range, 1.0–4.0 mm), with all patients demonstrating an increase in upper eyelid position. The difference between the group means was highly significant ( P Conclusions: Worsening of ptosis on downgaze is common with acquired ptosis and likely represents a normal physiologic process, which may exacerbate functional impairment of activities (i.e., reading) in this gaze position. The consistent increase in upper eyelid position on downgaze in patients with typical congenital ptosis is an abnormal differentiating sign.

A healthy 13-year-old female presented with a 5-month history of an enlarging red-brown, firm lower eyelid mass associated with loss of eyelashes. An excisional biopsy revealed a well-circumscribed nodule composed of coalescing nests of epithelioid cells, rare multinucleated cells, and vacuolated macrophages and spindle cells. Additional studies revealed a positive vimentin and alpha(1)-antitrypsin, and negative S100 protein and Factor XIIIa immunophenotype. This constellation of clinicopathologic features is diagnostic of solitary reticulohistiocytoma, but also shows overlap with xanthogranuloma, a common childhood histiocytosis. Reticulohistiocytoma should be considered in the differential diagnosis of eyelid tumors and has the potential for local recurrence. Diffuse cutaneous reticulohistiocytosis or multicentric reticulohistiocytosis should be considered if similar cutaneous lesions with or without symptoms of arthritis are present, respectively.

Backgroud/Aims: To report two rare cases of orbital myeloid sarcoma in adults and discuss special features relevant to this entity.Methods: Complete ophthalmologic and systemic examinations followed by incisional biopsy and pathological examination.Results: Two cases of myeloid sarcoma with orbital involvement were identified. Both cases presented with a clinical picture and imaging which demonstrated infiltrative orbital masses. When combined with 8 previous reported cases, 8/10 demonstrated systemic AML involvement.Conclusions: Orbital myeloid sarcoma is a rare entity in adults and highly associated with myelodysplastic syndromes, especially acute myelogenous leukemia (AML). It may present at any stage of AML and requires appropriate workup and treatment, though generally carries a poor prognosis.

Purpose The aim of this article is to describe complications of hydrogel (MIRAgel) scleral buckle implants that may appear many years after implantation, and to describe an effective technique to facilitate safe removal of these implants, which become extremely friable with time. Methods Four case reports of patients with complications of hydrogel orbital implants and a technique for removal of the implants are described with review of the literature. The technique involves a conjunctival incision into each involved quadrant, followed by use of blunt instrumentation for "push" and a Frasier suction handpiece for "pull" to allow segmental removal. This technique limits the tendency of the implant to fragment, which has been a problem described with previous techniques. Results Cases typically present simulating an orbital tumor or infection, with the diagnosis not immediately apparent, as was the case in 3 of 4 cases in our series. The technique we used allowed for expeditious removal and prompt recovery in all 4 patients. Conclusions Hydrogel scleral buckle implants can produce late complications that may be difficult to diagnose and manage. The "push-pull" technique described in this article facilitates effective removal, and may have implications for other types of orbital hydrogel implants as well.

To examine the tarsal attachments of the levator aponeurosis.Experimental anatomic study.Sixteen orbits from 12 fresh frozen white cadavers.Eight specimens served as controls. In the remaining 8 specimens from 4 cadavers, the upper eyelid was everted. All specimens then were fixed in formalin. The age, sex, and laterality were recorded in both groups. The eyelid lamellae and tarsal attachments of the levator aponeurosis in particular were examined microscopically. Lamellar and nonlamellar ocular anatomic features and the relationships of the preaponeurotic and postaponeurotic spaces were measured.Histologic findings of the extent and pattern of the tarsal attachments of the levator aponeurosis in relation to the tarsus and Müller's muscle and of the changes in the lamellae in eyelid eversion.The demographic and baseline anatomic characteristics of both the noneverted control and everted eyelid groups were similar. In comparing everted with noneverted controls, the preaponeurotic space was significantly shorter (6.22 and 10.61 mm, respectively; P = 0.003) and the preaponeurotic-to-postaponeurotic space ratio was halved (0.57 and 1.16, respectively; P = 0.005). Although the distance from the superior tarsal border to Whitnall's ligament increased significantly in everted versus noneverted eyes (14.65 and 11. 03 mm, respectively; P = 0.016), there was no significant difference in the length of postaponeurotic space in the 2 groups (11.07 and 9.69 mm, respectively; P = 0.370). The levator aponeurosis attached to the anterior tarsus in both groups. The proximal point of attachment was the superior border of the tarsal plate, adjacent to the insertion of Müller's muscle tendon.The deeper aponeurotic fibers and Müller's muscle attach proximally at the superior tarsal border. Upon eyelid eversion, the 2 lamellae move as a unit and the postaponeurotic space remains stable. A proximal tarsal attachment suggests that blepharoptosis procedures that advance an involutional or disinserted levator aponeurosis onto to the superior tarsus approximate that aspect of native anatomic features. In addition, posterior surgical approaches that address Müller's muscle may involve resections in closer proximity to the aponeurosis than previously thought.The author(s) have no proprietary or commercial interest in any materials discussed in this article.

The upper and lower eyelids, eyebrows, and midface all play a role in the overall aesthetics of the face. Importantly, concepts of beauty are varied throughout the world, with certain facial contours more desirable than others, depending upon the societal norms. These contours are created and altered by the individual characteristics of the eyelid margin, tarsal plate, orbital fat, levator aponeurosis, and the bony orbit. When considering upper eyelid blepharoplasty, each of these structures needs to be evaluated and addressed appropriately utilizing a variety of surgical techniques. Each patient has individual needs and concerns, as well as their own concept of beauty, which the surgeon must consider to ensure the correct techniques and the desired aesthetic outcome obtained. This customized approach to blepharoplasty requires a healthy patient–physician relationship that can ultimately be both satisfying and challenging.

A 43-year-old woman (Case 1), 63-year-old man (Case 2), and a 67-year-old man (Case 3) presented with diplopia (Cases 1, 2, and 3) and upper-eyelid ptosis (Cases 1 and 3). The cases had preceding cranial nerve V1 disturbances ranging from 3 months to 8 years. Each demonstrated complete internal ophthalmoplegia and external ophthalmoplegia. No case had a cutaneous squamous cell carcinoma (SCC) on presentation or by history. Imaging revealed isolated orbital apex masses. Tumor biopsies revealed SCCs of various differentiations. Systemic workup revealed no extraorbital malignancy. All received radiation therapy, and 2 patients underwent adjuvant chemotherapy. One patient is alive since diagnosis (49 months). In Case 2, SCC developed in the contralateral orbit, and the patient died 19 months after diagnosis; and Case 3 died 12 months after diagnosis. These isolated cases of orbital SCC may have arisen from orbital choristomatous squamous epithelium, may represent de novo or metastatic tumors, or may be manifestations of occult perineural spread.

To evaluate the functional indications and outcomes for blepharoplasty and blepharoptosis repair by assessing functional preoperative impairment and surgical results.Literature searches of the PubMed and Cochrane Library databases were conducted on July 24, 2008, with no age or date restrictions, and they were limited to articles published in English. These searches retrieved 1147 citations; 87 studies were reviewed in full text, and 13 studies met inclusion criteria and were included in the evidence analysis.The 13 studies reported the functional effects or treatment results of simulated ptosis; several types of blepharoptosis repair, including conjunctiva-Müller's muscle resection, frontalis suspension, and external levator resection; and upper eyelid blepharoplasty.Repair of blepharoptosis and upper eyelid dermatochalasis provides significant improvement in vision, peripheral vision, and quality of life activities. Preoperative indicators of improvement include margin reflex distance 1 (MRD(1)) of 2 mm or less, superior visual field loss of at least 12 degrees or 24%, down-gaze ptosis impairing reading and other close-work activities, a chin-up backward head tilt due to visual axis obscuration, symptoms of discomfort or eye strain due to droopy lids, central visual interference due to upper eyelid position, and patient self-reported functional impairment.The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Primary tumors of the lacrimal sac are rare, and mucoepidermoid carcinomas of the lacrimal sac have only been reported 13 times in the literature. We reported an intermediate-grade mucoepidermoid carcinoma that was managed with wide local excision, medial maxillectomy, and external beam radiotherapy, and the patient has remained disease-free for 7 years. Orbital exenteration had generally been recommended for these tumors, but newer, more conservative resections along with radiation therapy may be equally effective.

The lacrimal drainage system includes the nasolacrimal duct, lacrimal sac, and canaliculi. Stenosis or obstruction at any portion of the lacrimal drainage system or an impaired lacrimal pump may cause bothersome epiphora. Tear stasis may also be associated with ocular or adnexal infections. This article reviews the recent literature pertaining to anatomy and physiology, pathology, and clinical evaluation and treatment, as well as complications of lacrimal drainage-system disorders.

Quantitation of the effects of blepharoptosis on the visual field has largely been limited to manual kinetic perimetry using a single peripheral isopter. The authors evaluated the visual dysfunction caused by blepharoptosis using automated static full-threshold perimetry.A custom static full-threshold 60 degrees test strategy on the Humphrey field analyzer was used to assess the visual fields of 20 volunteers at their normal baseline and after inducing mild and moderately severe blepharoptosis by applying gold weights to the eyelids. Threshold sensitivities were measured at points along the eight principal meridians, separated by 45 degrees, traditionally used to assess visual field impairment.For mild blepharoptosis, essentially all test points along the superior meridian were significantly depressed (P0.01), with an increase in slope secondary to greater decreases in sensitivity at more eccentric points. For moderately severe blepharoptosis, depression of the superior meridian was expectedly greater than that seen with mild blepharoptosis. Additionally, depression of the horizontal meridians and to a lesser extent the lower meridians also was noted.These results suggest that even mild blepharoptosis may be associated with depression of the superior visual field extending close to fixation. Ophthalmologists should be aware of the effect of blepharoptosis when testing for other ophthalmic or neurologic disorders using automated static perimetry. Full-threshold static perimetry can be used to quantitate the visual field loss associated with blepharoptosis as a means of evaluating visual impairment.

INTRODUCTION Among specialty fellowships available in the United States, matching in ophthalmic plastic and reconstructive surgery (OPRS) is widely thought of as an exceptionally competitive process. There are articles discussing fellowship selection and competition in other fields of medicine; however, little information is available in the peer review literature regarding the process for OPRS. METHODS In this study, the authors evaluate match statistics, available from the National Resident Matching Program, for the class of fellows with appointments for training beginning in 2009. These statistics are compared with the 36 other advanced specialty training programs, in a wide range of medical and surgical fields, also participating in the Specialties Matching Service. RESULTS OPRS fellowships are 1 of only 5 specialties that filled all available positions in the 2009 match and 1 of only 3 programs to fill all available positions in each of the past 4 years. In addition, 88.9% of positions were filled by U.S. graduates, the highest among all programs (range = 5.0%-88.9%, mean = 54.8%). Of those applicants who matched, OPRS fellowships had the lowest percentage of applicants, 22.9%, match at their first choice program among single specialty matches (range = 22.9%-75.0%). A total of 48.6% of OPRS applicants did not match-the highest among single specialty matches and the second highest among all programs, including combined specialty matches (range = 4.3%-53.5%). CONCLUSIONS OPRS fellowships are among the most selective advanced specialty positions available in the United States. Among all specialty programs participating in the Specialties Matching Service, OPRS fellowships have nearly the highest unmatched applicant rate, highest U.S. graduate fill rate, and lowest first-choice match rate. These statistics indicate that the applicant pool is competitive and that both applicants and program directors (preceptors) are selective with their rankings. The authors believe these findings will be of interest to residents interested in further training in OPRS and to program directors, chairs, and others involved in the specialist educational process.

INTRODUCTION Competition for subspecialty fellowship positions in ophthalmology continues to grow, and there is increasing interest regarding the factors considered important in fellowship selection. While a previous report evaluated the characteristics and criteria used by ophthalmology subspecialty program directors to select fellows in retina, cornea/external disease, and glaucoma fellowship programs, to the authors' knowledge no such study has evaluated Ophthalmic Plastic and Reconstructive Surgery (OPRS) fellowships. METHODS The authors surveyed the program directors of all American Society of Ophthalmic Plastic and Reconstructive Surgery (ASOPRS)-sponsored fellowships in the United States and Canada. The survey contained 16 criteria related to the selection of fellows. A Likert scale ranging from 1 (not important) to 9 (very important) was used for prioritizing the criteria. Opportunity was afforded for comment on other measures, and program directors were also asked to select their most important factor used for fellow selection. RESULTS The return rate of the completed surveys was 35 of 48 (73%). The 3 criteria with the highest mean Likert scale scores were the interview process (8.7), the ability to work and communicate with others (8.5), and letters of recommendation from subspecialty faculty (7.8). Likewise, the criterion selected as the single most important by respondents was the interview (58%), the ability to work and communicate with others (15%), and letters of recommendation from subspecialty faculty (15%). CONCLUSIONS The authors' findings demonstrate that OPRS program directors place greater emphasis on qualities assessed during the interview, letters of recommendation from same specialty faculty, and the ability of the applicant to work and communicate with others. While not identical, our findings were similar to those noted for other ophthalmology subspecialties. The results support the suggestion that residents interested in fellowship training may benefit from faculty mentors in their area of interest early in their training. With the high interest in OPRS and other ophthalmology subspecialty fellowship training, the authors hope that this report will be useful to applicants, residency programs, and fellowship directors.

Background: The authors report on a 30-year-old man who presented with progressive bilateral exophthalmos over a 2-year period. Findings: Computed tomography showed large heterogeneous masses in the superior aspect of both orbits. Excisional biopsy via bilateral lateral orbitotomies showed the tumors to be well-circumscribed, relatively avascular, localized neurofibromas. The patient had several features suggestive of multiple endocrine neoplasia type IIB, including Marfanoid habitus, enlarged corneal nerves, thickened lips, and mucosal neuromas. Conclusion: Localized neurofibromas are rare in the orbit and, unlike plexiform neurofibromas, are not typically associated with von Recklinghausen's neurofibromatosis. Bilaterality of such localized neurofibromas has not been previously reported. Recognition of ophthalmic lesions suggestive of multiple endocrine neoplasia IIB should prompt evaluation for systemic manifestations of this disorder.

Raman spectroscopy on solid anhydrous sodium dithionite reveals that it exists in at least two forms in the solid state. MAS23Na NMR spectra and X-ray powder diffraction patterns of the solids indicate that sodium ions are in different environments in each form of the material. The results suggest that the dithionite anion is conformationally different in each lattice. A single crystal X-ray diffraction study of the recrystallized form of anhydrous sodium dithionite reveals an anion with C2 geometry and a 16° O-S-S-O torsional angle; nearly eclipsed. (Crystal Data for recrystallized Na2S2O4 area=6.539(1) A,b=6.552(1) A,c=6.578(1) A,V=240.0(1) A3,β=121.61(1)°, space group=P2/c,Z=2). Raman spectra of sodium dithionite dihydrate reveal that the dithionite ion is in a different conformation than in either of the anhydrous materials. A single crystal X-ray diffraction study of Na2S2O4·2H2O reveals a dithionite anion with a substantially shorter S-S bond length than in the anhydrous structure and an O-S-S-O torsional angle of 56°; approximately gauche. (Crystal Data for Na2S2O4·2H2O area=8.134(1) A,b=5.756(2) A,c=14.528(5) A,V=653.3(3) A3,β=106.20(2)°, space group=P21/n,Z=4). The structure of the dithionite anion is found to depend critically upon the nature of its external environment.

The pH tolerance of rabbit corneal endothelial cultures was determined for a balanced salt solution and various pharmaceutical vehicles in an effort to determine the biocompatibility of the different formulations after 4-128 min exposures. Acute damage was assessed by monitoring the release of radiolabeled nucleotides and corresponding changes in tissue morphology of the prelabeled cultures. Protracted damage was evaluated by re-examining the morphology of the same cultures after 24 hr along with quantitative measurement of 3H release, tissue loss, and concomitant changes in protein synthesis. Our testing results indicated that the permissive limits of a balanced salt solution were between a pH of 6 and 8, which is comparable to the guidelines for native endothelium in situ established by organ perfusion studies. In contrast, the permissive limits for prototypes of intraocular vehicles were frequently more restricted, since only unbuffered solutions at a neutral pH were relatively nontoxic. Topica...

The osmotic tolerance of rabbit corneal endothelial cultures was determined for a balanced salt solution and various pharmaceutical vehicles in an effort to determine the biocompatibility of the different formulations after 4-128 min exposures. Acute change was assessed by monitoring the release of radiolabeled nucleotides and corresponding changes in tissue morphology of the prelabeled cultures. Protracted damage was evaluated by re-examining the morphology of the same cultures after 24 hr along with quantitative measurements of residual 3H release, tissue loss, and concomitant changes in protein synthesis. Our testing results indicated that the permissive limit of a balanced salt solution was between 200 and 400 mOsm, which is comparable to the guidelines for native endothelium in situ established by organ perfusion studies. In contrast, the permissive limits for prototypes of intraocular vehicles were more restricted, since only isotonic formulations were relatively nontoxic. Topical vehicles, ...

Purpose To characterize the clinical and pathologic features of central lower eyelid thinning with trichiasis and discuss the management of this unique subset of entropion in elderly patients. Methods Retrospective study of patients with central lower eyelid thinning with trichiasis who presented between July 1996 and March 2006. Evaluation of management, including surgical intervention, using a modified Quickert "4-snip" block excision combined with lower eyelid retractor plication. Results Forty-one lower eyelids in 25 patients (22 men, 3 women; age range, 65-92 years; mean age, 79.6 +/- 6.6 years). All lower eyelids had medialization of the lateral eyelashes progressing posteriorly to frank trichiasis in the thinnest central zone. Seventeen patients (68%) had blepharitis. Twenty lower eyelids (48.8%) were refractory to initial treatment or presented with more severe disease and required incisional surgery; 16 of these were considered to have a successful postoperative outcome. Pathology reports from the specimens obtained frequently revealed the absence of meibomian glands, subconjunctival fibrosis, and tarsal scarring. Conclusions Central lower eyelid thinning with trichiasis is a distinct subset of entropion in elderly patients. Its management differs from the usual treatment for entropion in this age group. Surgeons should be aware of this unique condition to optimize diagnosis and treatment.

Purpose: To evaluate the frequency of acquired lacrimal sac fistula formation after incision and drainage for dacryocystitis and to determine associated risk factors. Methods: National multicenter retrospective study of acquired lacrimal sac fistula formation in patients receiving incision and drainage during the course of treatment for dacryocystitis between January 2005 and December 2007. Data collection included patient demographics, past medical history, procedure technique, culture results, and details of the medical and surgical management. The formation of a persistent fistula was ascertained, in addition to the subsequent treatment of the dacryocystitis. Results: Thirty-nine patients from 9 centers were included. Reasons cited for performing incision and drainage included a tense, pointing abscess, severe pain not relieved with narcotics, periorbital cellulitis, dacryocystitis refractory to antibiotics alone, and the need to control infection prior to dacryocystorhinostomy. In 33 of 39 patients (84.6%), incision and drainage and associated medical treatment cured the dacryocystitis. Only 2 of 39 patients (5.1%) developed a persistent fistula following incision and drainage. No risk factors of statistical significance were identified. Dacryocystorhinostomy to correct associated nasolacrimal duct obstruction was subsequently performed in 36 of 39 (92.3%). Conclusions: Incision and drainage of the lacrimal sac can be an appropriate adjunctive treatment strategy for selected cases of dacryocystitis. Incision and drainage provides appropriate culture media, symptomatic pain relief, and can facilitate resolution. In this series, persistent lacrimal sac fistula formation after incision and drainage and associated medical and surgical treatment for dacryocystitis was rare.

PURPOSE To evaluate the utility of transconjunctival fat removal combined with conservative ("strut-sparing") bony medial/floor orbital decompression for Graves orbitopathy. METHODS Retrospective, noncomparative case series of 52 orbits in 28 patients that underwent decompression using this technique. Preoperative and postoperative exophthalmos, diplopia, logMAR visual acuity, and orbital symmetry were measured. RESULTS Reduction in exophthalmos up to 8 mm with a mean of 3.3 mm (+/-1.5 mm) was achieved for decompressed orbits (p < 0.001). Postoperative symmetry within 2 mm was achieved in all patients. Diplopia was improved in 4 patients (14%), unchanged in 23 (82%), and worse in 1 (4%). Mean logMAR visual acuity improved -0.11 units (p = 0.007). CONCLUSIONS Orbital fat removal combined with conservative ("strut-sparing") bony medial/floor orbital decompression via a single transconjunctival incision is an effective and efficient technique with minimal morbidity.

Rabbit corneal basal epithelial cells seeded onto fixed gelatin membranes or commercial collagen shields formed 3 to 5 cell layers after 1 to 3 weeks of culture at 35 degrees C in nutrient medium. The cells grew better, by comparison, in the collagen shields and eventually formed a multilayered tissue that resembled the stratified morphology of native epithelium. Transfer of multilayered cultures (prior to stratification) from these carriers in vitro to denuded corneal buttons or cryolathed lenticules resulted in complete adhesion of the grafted tissue to the underlying recipient buttons after 24- to 48-h incubations. After mechanically removing the carriers, most of the epithelial cells remained attached to the stromal surface. Our experimental findings indicated that both kinds of carriers may be suitable for epithelial transplantation, although the collagen shield is probably superior because of its better biocompatibility and physical characteristics.

Human corneal buttons were exposed to Acanthamoeba castellanii trophozoites and cysts for 12 hours at 35 degrees C. The buttons examined by light microscopy and scanning and transmission electron microscopy had severe epithelial ulceration and penetration by trophozoites. Observations on trophozoites below the surface suggest that penetration is accomplished by both secreted cytolytic enzymes and phagocytosis. It is likely that the secretion of one or more enzymes constitutes the initial step in preparing the host tissue for endocytosis or that the secretory mechanism is used by the amebas to move through the outer squamous layer to the basement epithelium where phagocytosis occurs. Based on this study and a previous study, it appears that entry into the cornea is a two-step process involving adherence and penetration by trophozoites.

The anatomy of the orbital septum and associated eyelid connective tissues was examined using cadaver dissection, histologic sections, surgical observations, and special radiologic imaging. The embryologic development of the eyelid connective tissues was also reviewed. Examination revealed a distinct layer of fibroadipose tissue in the eyelid and eyebrow posterior to the orbicularis and frontalis muscles, and anterior to the orbital septum. Fibrous septa within the submuscular fibroadipose tissue become contiguous with more compact lamellae of the orbital septum posteriorly imparting a multilayered quality to the orbital septum. Fat within the fibroadipose layer anterior to the orbital septum may be mistaken for the preaponeurotic fat pad by the unwary surgeon and may lead to surgical error. The orbital septum and the levator aponeurosis were found to join 2 to 5 mm above the superior tarsal border (average, 3.4 mm). Recommendations for ptosis surgery based on these anatomic principles are given.

The impact of pH on the osmotic tolerance of stratified corneal epithelium in vitro was determined after the instillation of a balanced salt solution and various pharmaceutical vehicles to determine the biocompatibility of the different formulations after 4–64 min exposures. Acute damage was assessed by the release of [3H]nucleotides and corresponding changes in tissue morphology. Protracted damage was evaluated by re-examining the morphology at 24 hr, along with determination of residual 3H release, tissue loss, and concomitant changes in protein synthesis. Our data indicated that an interaction between pH and osmolality was important for determining the biotolerance of balanced salt solutions, which may be explained by their chelating properties. In contrast, the impact of pH on the biocompatibility of unbuffered salines and phosphate-buffered vehicles was not quite as striking, which indicated these factors were not nearly as critical in these types of formulations. More conventional topical ve...

The osmotic tolerance of stratified rabbit corneal epithelial cultures was determined for a balanced salt solution and various pharmaceutical vehicles in an effort to determine the biocompatibility of the different formulations after 4–128 min exposures. Acute damage was assessed by monitoring the release of radiolabeled nucleotides and corresponding changes in tissue morphology of the prelabeled cultures. Protracted damage was evaluated by re-examining the morphology of the same cultures after 24 hr along with quantitative measurements of residual 3H release, tissue loss, and concomitant changes in protein synthesis. Our testing results indicated that the permissive limits of a balanced salt solution were between 305 and 400 mOsm, which is comparable to the guidelines for native epithelium in situ established by organ perfusion studies. In contrast, the permissive limits for unbuffered and buffered intraocular vehicles were more restricted, since only isotonic formulations were relatively nontoxi...

The impact of chelation on the biocompatibility of various vehicles was determined after 1- to 32-min exposures using stratified rabbit corneal epithelial cultures. Each formulation was tested at either pH 5.0 or 7.5 to mimic the specifications of most commercial ophthalmic preparations. Adding ethylenediamine tetraacetic acid (EDTA) to balanced salt solutions was unremarkable, and all of the formulations were essentially nontoxic. In contrast, EDTA moderately reduced the toxicity of the acidic acetate/citrate-buffered vehicles, but enhanced the toxicity of the alkaline solutions. The preservative, on the other hand, had little impact on the biotolerance of acidic unbuffered and phosphate-buffered vehicles, although it also increased the toxicity of the alkaline formulations. These findings are interpreted in terms of the different pKa values of the chelating agents, and an unsuspected interaction between citrate and the preservative. We believe that this type of testing can be used to develop guidelines for the use of buffers, excipients and preservatives in commercial formulations.

A 55-year-old white man presented with orbital cellulitis and suspicion of an intraorbital foreign body after ocular trauma. He underwent orbital exploration, but no intraorbital foreign bodies were identified. Intraoperative orbital and conjunctival cultures grew Yersinia enterocolitica O:8. The patient's signs and symptoms resolved with intravenous antibiotic treatment after this exploratory orbitotomy. This is the first case, to our knowledge, of human orbital cellulitis caused by Y. enterocolitica O:8. The single visible interpalpebral conjunctival ulceration was suspected to be an entry wound by the patient's primary physician, the emergency room physician, and the orbital surgeon prior to surgical investigation, at which time all the other ulcerations were identified. Therefore, the physical manifestations of this rare but important infection are presented because they may mislead clinicians in suspecting an intraorbital foreign body.

Local anesthesia is appropriate for eyelid surgery, but patients fear the pain of injections. We evaluated iontophoresis of lidocaine for eyelid skin anesthesia to pinprick pain sensation in normal subjects, and prior to regional infiltration of the anesthetic agent in patients undergoing eyelid surgery. After iontophoresis of lidocaine hydrochloride 4% solution to one randomly chosen eyelid, pinprick skin sensation was tested in a double-masked manner. Subjective pain scores of 10 subjects were significantly less [P < .008} on the iontophoresis treated eyelids (0.25) than on the untreated eyelids (2.55). Nine patients undergoing bilateral upper eyelid surgery had iontophoresis applied to one randomly chosen eyelid prior to the usual anesthetic injections. In this doublemasked evaluation, patients reported significantly less pain (P

A widely utilized rabbit corneal cell line, SIRC, was characterized ultrastructurally and immunohistologically. Although SIRC cells are often described as being of epithelial origin, important ultrastructural and antigenic characteristics indicate that these cells are fibroblastic and not epithelial. SIRC cells lack desmosomes, cytoplasmic filaments, and cytokeratin-structures that are characteristic of corneal epithelial cells. By contrast, the dendritic morphology, presence of vimentin, and the extensive dense accumulations of ribosomes and rough endoplasmic reticulum are consistent with a fibroblastic phenotype. Collectively, the morphology, ultrastructural features, and antigenic composition favor the hypothesis that SIRC cells are fibroblastic cells (keratocytes) and not corneal epithelial cells.

Purpose To assess and compare the frequency of reflex sneezing occurring during periocular anesthetic injections with and without intravenous sedation. Design Retrospective, comparative case series. Methods Seven hundred and twenty-two patients undergoing oculoplastic surgical procedures were included in this study. Those who received a periocular anesthetic injection under intravenous sedation served as the test group of 381 subjects. Those who received a periocular anesthetic injection without intravenous sedation served as the control group of 341 subjects. The absence or presence of reflex sneezing in both groups was recorded and compared using Chi-square analysis. Results Of the 381 patients who received periocular anesthetic injections under intravenous sedation, 19 (5%) exhibited a vigorous sneeze. Conversely, none of the 341 patients who received periocular anesthetic injections without intravenous sedation sneezed ( P ≤ .001). Conclusions Surgeons, anesthesia staff, and other operating room personnel should be aware of this unusual and potentially dangerous sneeze phenomenon when periocular anesthetic injections are delivered under intravenous sedation to reduce potential ocular complications.

To investigate whether orbital radiation offers effective and safe treatment for Graves ophthalmopathy.Medical literature databases were searched to identify all published reports relating to orbital radiation treatment for Graves ophthalmopathy. To be included in the technology assessment, reports had to provide original data, to report on a case series or uncontrolled trial of at least 100 subjects or a randomized clinical trial of any size, to focus on orbital radiation for the treatment of Graves ophthalmopathy, and to follow-up patients for at least 3 months. Abstracted data included study characteristics, patient characteristics, treatment response, and safety information.Fourteen studies were included in the technology assessment: 5 observational studies and 9 randomized controlled trials. Three of the observational studies report on treatment response, with overall favorable outcomes for 40% to 97% of patients. Three of the observational studies provided intermediate-term safety data. The risk of definite radiation retinopathy is 1% to 2% within 10 years after treatment. Patients treated with orbital radiation did not have an increased risk of secondary malignancy or premature death. The 9 randomized trials were qualitatively heterogeneous. Patients with optic neuropathy generally were excluded from participating in the randomized trials. Three of the randomized trials were sham controlled. None of these studies showed that orbital radiation was more efficacious than sham irradiation for improving proptosis, lid fissure, or soft tissue changes such as eyelid swelling. Two of the 3 sham-controlled randomized trials demonstrated improved vertical range of motion in radiation-treated subjects compared with controls.Systematic review of the effect of orbital radiation on Graves ophthalmopathy is limited by the lack of standardization and variable quality of published reports. Extraocular motility impairment may improve with radiotherapy, although the evidence of a treatment effect is mixed in clinical trials. Future studies are needed to determine if a potentially beneficial motility effect results in improved patient function and quality of life. Level I evidence indicates that proptosis, eyelid retraction, and soft tissue changes do not improve with radiation treatment. The efficacy of orbital radiation for compressive optic neuropathy resulting from Graves ophthalmopathy has not been investigated in clinical trials and merits further study. Radiation retinopathy, although rare, is a risk of orbital radiation, even in patients without diabetes who receive appropriate radiation dose and delivery.

PURPOSE To examine the microbiologic spectrum of dacryocystitis, specifically characterizing differences between acute and chronic infection. METHODS National multicenter prospective study of the microbiologic spectrum of acute and chronic dacryocystitis based on culture results reported between March 2005 and March 2006. Chi-square analysis was used to compare differences between groups. RESULTS Eighty-nine patients from 16 centers were included: 21 (23.6%) patients had acute infection and 68 (76.4%) had chronic infection. Of all 89 patients, there were 80 total culture isolates with 55 (68.8%) Gram-positive isolates, 23 (28.7%) Gram-negative isolates, and 2 (2.5%) Mycobacterium isolates. In the acute group, 18/23 (78.3%) were Gram-positive and 5/23 (21.7%) were Gram-negative. In the chronic group, 37/57 (64.9%) were Gram-positive, 18/57 (31.6%) were Gram-negative, and 2/57 (3.5%) were Mycobacterium isolates. The proportions of Gram-positive and Gram-negative organisms between groups revealed no statistically significant difference (p > 0.20). The frequency of methicillin-resistant Staphylococcus aureus (MRSA) in the acute group, 4/23 (17.4%), was greater than the chronic group, 1/57 (1.8%) (p < or = 0.01). CONCLUSIONS Gram-positive organisms were much more common than Gram-negative organisms overall, and the proportions did not differ significantly between the groups. Staphylococcus was the most common isolate in both groups, but there was a greater frequency of methicillin-resistant Staphylococcus aureus (MRSA) isolates in the acute group. The results of this study have important implications for the treatment of dacryocystitis.

To report the frequency and relationship of eyelid retraction, lid lag, lagophthalmos, and von Graefe's sign in a group of patients with Graves' ophthalmopathy and compare these findings to those in a group of normal individuals.Retrospective comparative cohort study.Fifty consecutive Graves' ophthalmopathy patients were compared to a control group of 50 normal individuals.Measurements were made of eyelid position in primary gaze and downgaze to assess eyelid retraction and lid lag, and the presence of lagophthalmos and von Graefe's sign was noted when present.Eyelid position in primary gaze and downgaze and presence of lagophthalmos and von Graefe's sign.In the Graves' group, eyelid retraction (38%), von Graefe's sign (36%) and lagophthalmos (16%) were observed at a significantly greater frequency (P0.01) than in normals, whereas true eyelid lag was observed in only 8% (P = 0.67).The terms lid lag and von Graefe's sign have been used interchangeably in the past; however, they are distinct signs of downgaze-related upper eyelid static position and dynamic movement, respectively. Although von Graefe's sign was commonly exibited in Graves' patients, the relatively low frequency of lid lag suggests that factors other than restriction/fibrosis are likely responsible for the etiology of eyelid retraction in many cases.

A 36-year-old man developed acute visual loss, mimicking an optic neuritis in the left eye. Cranial magnetic resonance imaging revealed a sphenoid sinus mucocele with extension into the anterior clinoid process abutting the left optic nerve. Endoscopic marsupialization of the mucocele led to marked improvement of vision. Sphenoid sinus mucocele is discussed, as is the differential diagnosis of optic neuritis.

Antibiotic stewardship is important in controlling resistance, adverse reactions, and cost. The literature regarding antibiotic use for eyelid surgery is lacking.To determine standard care and assess factors influencing antibiotic prescribing practices for eyelid surgery.A survey study was conducted from February 2, 2014, to March 24, 2014. The survey was distributed to 2397 oculoplastic surgeons in private and academic oculoplastic surgery practices in 43 countries. All surgeons were members of ophthalmic plastic and reconstructive surgery societies. Data were analyzed by geographic location. Linear regression was performed to quantify contributions to rates of prescribing postoperative antibiotics for routine eyelid surgical procedures.Rates of prescribing prophylactic intravenous, oral, and topical antibiotics as well as factors that influence surgeons' prescribing practices.A total of 782 responses were received from 2397 surgeons (average response rate, 36.7%; 2.5% margin of error) from 43 countries. Topical antibiotic use was common in all regions (85.2%). Perioperative intravenous antibiotic use was uncommon in all regions (13.5%). Geographic location was the greatest predictor of antibiotic prescribing practices (range, 2.9% in the United Kingdom to 86.7% in India; mean, 24%). Within Europe, Italy had the highest rate of antibiotic prescriptions for eyelid surgery (41.7%) and the United Kingdom had the lowest rate (2.9%.) In South America, Venezuela had the highest rate of antibiotic prescriptions for eyelid surgery (83.3%) and Chile had the lowest rate (0%). The practice locations that were associated with routinely prescribing postoperative oral antibiotics were India (odds ratio [OR], 15.83; 95% CI, 4.85-51.68; P .001), Venezuela (OR, 13.47; 95% CI, 1.43-127.19; P = .02), and Southeast Asia (OR, 2.80; 95% CI, 1.15-6.84; P = .02). Conversely, practice location in the United Kingdom (OR, 0.048; 95% CI, 0.0063-0.37; P = .004), Australia and New Zealand (OR, 0.15; 95% CI, 0.033-0.67; P = .01), and the United States and Canada (OR, 0.41; 95% CI, 0.23-0.72; P = .002) were associated with decreased rates of postoperative oral antibiotic use. Surgeons' concern for allergic reactions was associated with decreased rates of prescribing antibiotics (OR, 0.34; 95% CI, 0.23-0.49; P .001), while surgeons' concern for infection was associated with increased rates of prescribing antibiotics (OR 1.80; 95% CI, 1.45-2.23; P .001).These results from members of ophthalmic plastic and reconstructive surgery societies confirm that antibiotic prescribing practices for routine eyelid surgical procedures vary widely throughout the world. No standard of care has been established that would require the routine use of postoperative prophylactic antibiotics following eyelid surgery.