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Objective: To assess the role of colour Doppler flow imaging (CDFI) in the diagnosis and management of lacrimal fossa lesions., Methods: Institutional ethical committee approval was obtained. Fifty-one patients with 62 lacrimal fossa lesions were retrospectively included from 2003-2015. All patients underwent conventional ultrasonography and CDFI, with a qualitative and quantitative analysis of the vascularization. All patients had lacrimal gland surgery. Definitive diagnosis was based on pathological examination., Results: The study included 47 non-epithelial lesions (NEL) and 15 epithelial lesions (EL), with 24 (39 %) malignant lesions and 38 (61 %) benign lesions. NEL were significantly more likely to present with septa (p < 0.001), hypoechogenicity (p < 0.001), high vascular intensity (p < 0.001), both central and peripheral vascularization (p < 0.001), tree-shape vascularization (p < 0.05) and a low resistance index (RI) (p < 0.0001). EL were significantly more likely to present with the presence of cysts (p < 0.001), and a higher RI. Receiver operating characteristic curves identified a RI value of 0.72 as the best cut-off to differentiate NEL from EL, with a sensitivity and specificity of 100 %., Conclusion: CDFI is a valuable tool in the differential diagnosis of lacrimal fossa lesions. Resistance index measurement enables substantial distinction between EL and NEL, thus providing crucial data for surgical management., Key Points: • CDFI is a valuable tool in lacrimal fossa lesions. • Resistance Index measurement enables substantial distinction between epithelial and non-epithelial lesions. • Management of patients becomes more appropriate.

Cavernous hemangioma is the most frequent benign orbital tumor in adults. The purpose of this study was to examine its clinical features, to define surgical indications, and to determine the roles of the various surgical approaches praticed in ophthalmology: transconjunctival (increasingly utilized), anterior transcutaneous, and lateral orbitotomy. The records of all patients treated for orbital cavernous hemangioma (OCH) since 2004 at the Fondation Rothschild (Paris, France) were retrospectively reviewed. Forty-three patients were treated for orbital cavernous hemangioma. Fifty-eight percent were women, mean age 50.2; 79 % of the tumors were intraconal. Among those patients, 36 underwent surgical removal, 5 were followed periodically, and 2 were lost to follow-up. The main surgical indications were: optic nerve compression (26 patients), proptosis (24 patients) and diplopia (3 patients). Transconjunctival, anterior transcutaneous and Kronlein approaches were used in 16, 12 and 4 patients respectively. Four patients had intrapalpebral hemangiomas easily reached transcutaneously. Two patients demonstrated transient partial 3rd nerve palsy (one with the lateral orbitotomy approach and one with the transconjunctival approach), one patient with the lateral orbitotomy approach developed a palsy of the superior branch of the 3rd nerve, and one patient with the transcutaneous anterior approach developed mydriasis. Surgical excision of OCH's is required in the presence of clinical complications. The transconjunctival approach is a safe technique which can lead to complete resection of the tumor in most cases., (Copyright © 2013 Elsevier Masson SAS. All rights reserved.)

Purpose: To describe the management of orbital exenterations and the surgical techniques for the reconstruction of orbital exenteration cavities., Patients and Methods: This retrospective study includes 56 patients who underwent orbital exenteration between 2000 and 2009. Patients' age at the time of exenteration, diagnoses, complications and reconstructive techniques were studied., Results: Fifty-six patients - 31 male and 25 female patients - who underwent orbital exenteration between 2000 to 2009 were included in the study. The mean age was 62.5 years at the time of exenteration. Average follow-up was 23 months. The principal diagnoses were basal cell carcinoma of the eyelids (25%) and conjunctival melanoma (20%). For orbital reconstruction, 18 patients (32%) had a muscle flap, and 24 patients (43%) underwent secondary reconstruction by bone-anchored implants after spontaneous epithelialisation of the orbit. Approximately 50% of the patients received postoperative radiation therapy., Discussion: Surgical reconstruction using muscle flaps may mask recurrent tumor. Epithelialisation and bone-anchored implants supporting the prosthesis allow for recurrent cancer surveillance while providing better stabilization of the prosthesis. Radiation therapy seems to render the orbit more fragile and thus less stable for implants., Conclusion: Orbital exenteration is a mutilating technique. Rehabilitation techniques have been improved, in particular the bone-anchored implants which allow adaptation of the prosthesis with satisfactory cosmetic results., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Evaluation of a patient with orbital disease needs a multidisciplinary approach. Clinical examination should seek to glean information regarding pathophysiologic effect and location and to evaluate consequences of this disease on cosmetic, vision and ocular motility. Procedures of imaging are based on the implied complementary exams that should be done according to the suspected clinical location and characters help to characterize the underlying process. Imaging can define the location, size, limits and relationship of the disease to other tissues and especially to the vascular system. It may be completed by blood test. The final diagnosis is based on several arguments and can appeal for a diagnostic biopsy in the most difficult cases., (Copyright © 2012 Elsevier Masson SAS. All rights reserved.)

Purpose: To describe a case series of patients investigated in internal medicine for an inflammation of the orbit and to clarify the clinical and pathological features of patients with idiopathic orbital inflammatory syndrome (IOIS)., Patients and Methods: Forty patients were consecutively referred by a specialized center where an orbital biopsy was performed in case of accessible lesion. Eleven patients were excluded because of missing data or diagnosis of lymphomas, periorbital xanthogranulomas, or Graves' disease. Patients with systemic disease (SD) or auto-immune disorder (AID) that validated the international criteria, or those having an IOIS in the absence of local or systemic etiology, were included. The clinicopathologic and immunologic characteristics of IOIS patients, their treatment and their evolutionary profiles are reported according to the histological types described by Mombaerts., Results: Of the 29 patients enrolled, eight had a dacryoadenitis revealing a SD/AID, mainly a necrotizing vasculitis, seven patients had a presumed IOIS and 14 an IOIS histologically documented. The presentation of IOIS was dominated by a diffuse involvement of the orbit. Corticosteroids were administered alone or with an immunosuppressant in 57 and 24% of IOIS patients, respectively. The incidence of relapse/resistance was higher than that of remission, particularly in case of presumed IOIS or in its classical form. All four patients with a stage III-IV of Chisholm were relapsing or resistant., Conclusion: A dacryoadenitis may reveal some types of SD/AID. Unlike the severe sialadenitis, the form of sclerosing IOIS may not be a factor associated with relapse or resistance., (Copyright © 2011 Société nationale française de médecine interne (SNFMI). Published by Elsevier SAS. All rights reserved.)

Background and Purpose: Palpebral AVMs (pAVMs) are rare vascular lesions for which the treatment is challenging. Our aim was to present the technical aspects of the presurgical treatment by interventional neuroradiology of pAVMs and to report the clinical and angiographic results of combined (interventional neuroradiology/surgery) treatment of these malformations., Materials and Methods: Nine patients (5 females, 4 males) with a mean age of 22 years (range, 12-35 years) were treated in our department from December 1992 to April 2007 for superficial pAVMs. Seven patients presented with isolated pAVMs, while 2 had hemifacial AVMs. Ten TAE procedures, by using a liquid embolic agent (glue or Onyx) or microparticles, were performed in 7 patients. Six patients underwent absolute alcohol, glue, or sclerotic agent injection by direct puncture in 8 procedures. Clinical and angiographic follow-up were performed with a mean delay of, respectively, 6.3 and 5 years., Results: Three patients had a single EVT. Iterative procedures were performed in 5 patients. In 1 patient, EVT was not performed because of the risk of occlusion of the central retinal artery. No complication occurred except 1 case of transient palpebral hematoma. No visual acuity loss related to an endovascular procedure was reported. Exclusion of the AVMs at the end of the procedure was >75% in all cases and total in 3/8 cases. All the patients except 2 underwent at least 1 surgical procedure after the embolization. Good clinical regression of the mass was obtained in all patients at long-term follow-up., Conclusions: Combined endovascular and surgical treatment of pAVMs is an effective and safe technique with good clinical results at long-term follow-up.

Introduction: myasthenia gravis is a neuromuscular junction disorder that can jeopardize the patient's life and has a high clinical polymorphism that makes it difficult to diagnose., Patients and Methods: after reviewing the disease physiology, its clinical symptoms, and the different means to diagnose and treat it, we present a 15-patient series that we cared for at the Rothschild ophthalmologic foundation from 2002 to 2007 for myasthenia gravis that began with isolated ocular symptoms, so as to highlight the clinical diversity of this pathology., Results: when the disease was diagnosed, 11 patients out of 15 had a ptosis with diplopia, two had an isolated ptosis, and two had isolated diplopia. After investigations, we discovered that three patients had a malignant thymoma and one had thymic hyperplasia. An autoimmune disease association was found in two patients: the first one had Hashimoto thyroiditis and the second one developed optical neuromyelitis a few years after his myasthenia gravis. Only three patients secondarily developed a generalized myasthenia gravis., Discussion: our series of patients has a low disease generalization rate in comparison with the published data in the medical literature, indicating that two-thirds of patients with ocular myasthenia gravis should develop generalized myasthenia gravis within approximately 2 years after the beginning of their illness. This could be explained by the early consultation of these patients and the common prescription of an immunosuppressive therapy, reducing the risk of secondarily generalized myasthenia gravis according to some studies., Conclusion: despite the small number of patients, this study underlines the clinical polymorphism of ocular myasthenia gravis and the risks it may cause. Close collaboration between ophthalmologists and neurologists is needed to ensure good care for these patients., (2010. Published by Elsevier Masson SAS.)

Purpose: In Graves' orbitopathy, the volumetric increase of the oculomotor muscles and orbital fat leads to exophthalmia and a rise in orbital pressure. This rise in pressure may be implicated in the appearance of a compressive optic neuropathy. To investigate this increase in pressure and its variations accompanying surgical decompression, systematic measurements were taken before, during, and after every case of orbital decompression in Graves' disease., Results: The intraorbital pressure before the surgical procedure was 14.05 mmHg ± 9.19 for a normal value estimated in the literature at 4 mmHg ± 1.5 (statistically significant difference, P<0.0001). In the group presenting a compressive optic neuropathy (NO), the preoperative pressure was 26.8 mmHg ± 7.85 versus 9.8 mmHg ± 4.2 in the group without NO: the pressure was significantly higher in the group with NO (P<0.001). After orbital decompression (one to three walls depending on the severity of the exophthalmia), the pressure was measured at 4.3 mmHg ± 2.53 for the entire series: 6.4 mmHg ± 2.07 in the group with NO versus 3.6 mmHg ± 2.32 in the group without NO (significant difference, P<0.05). The total decrease in pressure induced by the surgery was 9.75 mmHg ± 7.55 and was significantly greater for the group with NO: reduction of 20.4 mmHg versus 6.2 mmHg for the group without NO (P<0.001). The reduction in pressure was greater after collapse of the first wall (floor) than after collapse of following walls for all groups (P<0.001). The maximum pressure observed during the intervention (caused by the instruments) was measured at 78.3 mmHg ± 23.47 without pupillary changes., Discussion: This study shows that the intraorbital pressure is increased in Graves' orbitopathy and more in serious forms with compressive optic neuropathy. Orbital decompression, as its name indicates, provides decompression and a return to a near-normal orbital pressure situation. Compressive optic neuropathy does not result only from the direct compression of the oculomotor muscles on the optic nerve, but also from an overall rise in the pressure level within the orbital cavity., Conclusion: Intraorbital pressure is increased in Graves' orbitopathy, participating in the appearance of compressive optic neuropathy. Orbital decompression provides a significant reduction in intraorbital pressure., (Copyright © 2010 Elsevier Masson SAS. All rights reserved.)

Nasal sinus mucoceles are an uncommon cause of painful optic neuropathy. We report the case of a patient presenting an acute compressive optic neuropathy related to an anterior clinoid mucocele. The diagnosis was mainly made with CT and MRI, and the patient was treated with endoscopic endonasal transseptal surgery 10 days after the beginning of the disorder. Visual recovery was complete 3 days later. We review the literature on the etiologies of this type of pathology, the work-up, and the possible treatments.

Dysthyroid orbitopathy is a disease that is edematous and inflammatory, generally chronic, sometimes subacute or acute, and is characterized by exophthalmos in the majority of cases, retraction of the lid, restrictive strabismus with diplopia, corneal ulceration, ocular hypertension, and compressive optic neuropathy. Proptosis is the cardinal sign. Exophthalmos is frequently axial and is bilateral in 85%-90% of cases. Displacement of the globe in the vertical and horizontal axes is not rare, particularly when intense enlargement of an extraocular muscle produces a mass effect. Proptosis stems from a conflict for the space in the orbital cavity. The infiltration of the fat, muscles, and lacrimal gland by lymphocytes, plasma cells, and mucopolysaccharides, which are very hydrophilic, all contribute to the orbitopathy. The majority of patients with minimal exophthalmos do not require special treatment since they tend to improve spontaneously. In severe forms, it is important to evaluate the activity for steroid use to eliminate the inflammation in the soft tissues and to make rehabilitative surgery possible under better conditions. When a good response is not obtained, radiotherapy is evaluated. The surgical treatment by bone orbital decompression and sometimes lipectomy is indicated in inactive forms, disfiguring exophthalmos, certain particular cases such as dysthyroid optic neuropathy, ocular hypertension, corneal exposition.

Aging around the eyes plays a considerable role in facial aging. The demand for periocular rejuvenation is increasingly frequent. Until the past few years, eyelid esthetics was synonymous with blepharoplasty: surgery that consisted in resecting the myocutaneous excesses and reducing fatty deposits. The contribution of new medical and surgical treatments combined with new and more rigorous analysis of the esthetic disorders makes it possible to respond more precisely to patient demand and individualize surgical and/or medical treatment that is not highly aggressive and only uses products that are well tolerated, biocompatible, or resorbable.

Emergencies in childhood orbital tumorals are rare. The absolute emergency involves malignant primary orbital tumors, such as rhabdomyosarcoma or secondary malignant tumors (metastatic neuroblastoma, leukemia), involving a vital prognosis requiring prompt diagnosis. Delayed emergencies are usually vascular lesions. Among these lesions, immature orbital hemangioma, with a good prognosis, must be distinguished from orbital adnexal lymphangiomas, which are less frequent but can lead to dramatic cosmetic and functional disorders. In rare cases, they can be responsible for sudden, painful proptosis, due to orbital hemorrhage, with a risk of optic nerve compression, requiring emergency surgical treatment. Neurogenous lesions, either isolated, such as in gliomas, or associated with a systemic disease, such as Recklinghausen neurofibromatosis, threaten the functional prognosis. Diagnosis of pediatric orbital tumors is based on a good clinical examination, precise imaging investigations, and evaluation of the locoregional extension of the tumor. Biopsy is required in emergency situations, when rhabdomyosarcoma is suspected, in order to start the chemotherapy. However, the biopsy can be superfluous, and even useless or dangerous, when clinical and imaging investigations are sufficient to provide a diagnosis of capillary hemangioma, lymphangioma, or metastatic tumor from an abdominal malignancy. Treatment is closely related to the etiopathogenesis of the tumor. The outcomes are vital, functional and cosmetic. They may require orbital surgery (biopsy, tumoral resection, orbital decompression in case of a compressive hemorrhage), systemic corticotherapy (as in immature adnexal hemangioma), radiation, and chemotherapy (rhabdomyosarcoma, secondary malignant tumor). These diseases require a pediatric ophthalmological medical center specializing in orbital surgery, with close collaboration of multiple specialists such as onco-pediatricians and neurosurgeons.

Purpose: Dysthyroid Optic Neuropathy (DON) can lead to irreversible visual loss. We report risk features correlated with poor visual recovery despite an intensive treatment in a series of patients with DON., Design: Retrospective analysis of a non-comparative interventional series., Methods: Between 1997 and 2007, 300 consecutive patients with Graves' orbitopathy were seen at the Rothschild Foundation (Paris). Medical records of all consecutive patients who developed a DON were reviewed. Demographic, clinical features and visual function were collected at the time of the first onset, one month follow-up after medical and sometime surgical treatment and at the last examination. Statistical analysis (reflected as p values) gathered the significant observations into detrimental visual recovery prognostic factors for DON., Results: Fifty-six eyes of 29 patients developed a DON. Sixteen eyes (28%) did not improve vision despite usual treatment (intravenous steroids and surgical decompression when necessary). An inferior altitudinal visual field defect (AVF, p=0.0004) and/or a lack of response to intravenous steroids boluses (p= 0.011) were related to a poor recovery., Conclusion: DON prognosis is highly variable. Our results suggest that a non-inflammatory element, probably vascular could be involved in atypical DONs. An earlier recognition could prompt to rapid surgical treatment for these patients.

Introduction: Orbital organic foreign bodies are rare and can present different clinical features. The objective of this report is to show the danger of this type of foreign body, present the imaging data, and suggest a diagnostic approach and therapeutic management. We describe three cases of orbital organic foreign bodies with three different clinical presentations., Case Reports: The first case was a 43-year-old male complaining of a chronic cutaneous fistula of the inferior right eyelid lasting 4 months after an orbital trauma with a wooden object. Two surgeries were necessary to extract the foreign bodies. In the second case, a 37-year-old female with post-traumatic ptosis after a bicycle accident several months before, the imaging exams revealed a fracture of the left orbital ceiling and a superior extraconical foreign body that was removed by a neurosurgery approach. The third case, a 69-year-old male with a right orbit abscess following a trauma with a tree branch had a persistent right orbit inflammation lasting 4 months despite two drainage surgeries and an extraction of an orbital organic foreign body. A third surgery was necessary to completely extract the foreign bodies., Discussion/conclusion: Detecting an orbital organic foreign body is sometimes difficult, especially when the clinical history is unclear, the ophthalmologic exam reveals no abnormalities, or if the patient is referred to the hospital several months after the traumatic event. Orbital organic foreign bodies can lead to potentially serious orbital or intracranial complications. Computed tomography and orbital ultrasound sometimes do not yield an evocative pattern: for instance, in computed tomography, the low density of wood can be misdiagnosed as air. On the other hand, these foreign bodies can persist in the orbit after several surgical explorations because they can easily break or migrate. Magnetic resonance imaging is useful when an orbital organic foreign body is suspected, but the analysis is easier when clinical data are suggestive.

We describe an adult without microphthalmos who developed an acquired compressive optic neuropathy secondary to an orbital cyst which showed direct communication with an optic disc pit. Such pits may be revealed by late complications such as orbital compressive cyst of the optic nerve, even in previously normal adult patients.

Purpose: Orbital lymphangioma is a rare vascular malformation; it is a benign but severe anomaly because of its infiltrative, diffuse, and hemorrhagic nature, and its high morbidity rate. Surgical resection is a real challenge on account of the intricate architecture of the lesion. The authors report their surgical experience concerning two cases of diffuse orbital lymphangioma whose diagnosis was established in adulthood and whose surgical treatment was successful., Case Reports: Two patients presented with adult orbital lymphangioma. Progression was slow during the first decade and then was quickly followed by complications: major exorbitism, compressive optic neuropathy, and corneal exposure. Neuroimaging showed a diffuse and cystic orbital malformation. Surgical resection was performed as completely as possible, in one case with a Krönlein orbitotomy and in the other case only via a conjunctive route. An aspirate drain was put in the orbit for 48 h so as to prevent dead spaces forming after resection, an essential risk factor of hemorrhagic or cystic recurrence. Systemic corticotherapy was administered for the 5 days following surgery. The resection was total in one case and subtotal in the other. The surgical follow-up was uneventful with an excellent aesthetic result and an improvement in visual acuity. After 12 months, no tumoral or hemorrhagic recurrence was noted., Discussion: The surgical treatment of orbital lymphangiomas is challenging because of their infiltrative nature. In diffuse forms, a complete resection is rarely possible because of the risk of sacrificing visual function. In the two cases reported herein, the resection of the extraconal portion was complete, but the intraconal portion was completely removed only in one case. Using the aspirate drain, negative pressure was maintained in the orbital cavity, preventing the formation of chocolate cysts induced by surgery. Although the clinical result was very satisfying, long-term follow-up is necessary to evaluate recurrence., Conclusion: Diffuse orbital lymphangiomas can be treated successfully with a subtotal resection without clinical recurrence in the short term. These results are promising because they demonstrate that many orbital lymphangiomas can benefit from surgical treatment with an excellent esthetic and functional result.

Therapy for orbital pseudotumor, also called idiopathic orbital inflammation, is nonspecific and mainly based on the use of corticosteroids. Two patients with steroid-dependent idiopathic orbital inflammation, one with myositis and the other with dacryoadenitis, and intolerant of standard steroid sparing agents (methotrexate or azathioprine), were treated with infliximab, a monoclonal antitumor necrosis factor alpha antibody. In both patients, orbital manifestations disappeared following treatment. After follow-up for at least 20 months, the 2 patients still receiving infliximab remained event free. Infliximab enabled steroid tapering to less than 5 mg per day, suggesting that infliximab could constitute an alternative to conventional steroid sparing agents.

Purpose: The position and appearance of the upper eyelid crease is one of the challenges in eyelid surgery. The aim of this study was to compare the clinical appearance of the upper eyelid crease with its anatomy, including the position of the levator, the septum, and the orbital fat as determined by Magnetic Resonance Imaging (MRI)., Materials and Methods: Oculoplastic examination was performed in normal volunteers of the same age with different appearances of the upper eyelid. MRI (Intera 1.5 T, Philips, the Netherlands) was carried out with both head and surface coils in all volunteers. Subjects were asked to keep their eyes closed during the whole procedure, thus reducing artefacts due to eyeball movements. The protocol lasted 8 minutes and included a multiplanar scout to obtain T1-weighted 3D-images. Thin sagittal T2 sequences were obtained along the plane of the optic nerve and focused on both orbits, allowing a precise analysis of the orbital content and eyelid anatomy., Results: Six volunteers were included in this prospective study, three of Caucasian origin and three of North African, Central African and Asian origin, respectively. We distinguished two appearances of the crease: in some cases, the superior eyelid sulcus was convex, while in other cases it was concave. The superior eyelid fold was either high or low. Two Caucasian subjects had a deep, concave superior eyelid sulcus with a high crease. This crease appearance was correlated with a short concave appearance of the septum, which pulled back the pre-aponeurotic fat. The non-Caucasian volunteers all had a convex superior eyelid sulcus. The orbital septum insertion was low on the levator aponeurosis, and the orbital fat pad drooped onto the levator muscle, accounting for the convexity of the upper eyelid sulcus. A skin fold was formed by redundant skin over the crease., Conclusions: MRI provides excellent images and allows a good analysis of the upper eyelid components. It permits a detailed analysis of the architecture for a better understanding of its appearance and of the crease position, although further investigation with a larger number of volunteers is required.

Introduction: Forty percent of thyroid-related orbitopathies are associated with strabismus. In the healing phase of disease, fibrous hypertrophy of extraocular muscles may result in restrictive myopathy. We report our experience of surgical management in these cases., Patients and Methods: We present a retrospective case series conducted on 42 patients, operated between September 1998 and April 2003. All patients underwent complete oculoplastic and orthoptic examinations. Muscular recession was performed in all cases, with general anesthesia in cases of clinical muscular restriction; adjustable recession with topical anesthesia was performed in cases of moderate muscular restriction. Postoperative alignment and elimination of diplopia in the functional position of the gaze were evaluated., Results: The study included 42 patients (28 women, 14 men) with a mean age of 51 years. The mean follow-up was 48 months (range, 10 months to 6 years). Twenty-six patients presented vertical diplopia, 11 horizontal diplopia, and five mixed diplopia with a vertical and a horizontal component. These patients were operated on twice, beginning with vertical surgery. In cases of general anesthesia, muscular recession was adapted to an intraoperative forced duction test and a muscular elongation test. We obtained 94% good results for vertical diplopia and 81% for horizontal diplopia. Incomplete results were under correction. Adjustable muscular recession was adapted to intraoperative evaluation with patient participation. All patients had good results., Conclusion: Successful surgical treatment depends on precise identification of the muscles that are restricting motility and producing misalignment. We insist on the importance of an intraoperative forced duction test and a muscular elongation test in case of clinical muscular restriction. Adjustable surgery is useful in cases of moderate muscular fibrosis.

The complications of blepharoplasty are infrequent, most often minor and transient, and rarely major and permanent with functional or aesthetic consequences. Treatment is above all preventive with screening of "at risk" patients in whom blepharoplasty would be contra-indicated. Patients must be informed of possible risks through informative booklets stressing the most important points. The complications may affect vision. Partial or complete visual loss due to ischemic optic neuropathy, or rarely to compression of the ocular globe by intraorbital hemorrhage, is the most serious complication. Other visual complications include oculomotor disorders, keratoconjunctivitis sicca, epiphora, and chemosis of lymphatic origin. Eyelid complications are more frequent: ptosis of the upper eyelid or lagophthalmia caused by incorrect resection of the skin, scarring, and eyelid fold anomalies. The most severe aesthetic complication is the malposition of the lower eyelid resulting in retraction, lagophthalmia, ectropion, deformation of the external canthus, or lower eyelid tissue relaxation. These malpositions are often minor, sometimes reversible, but they can be major, with psychological, aesthetic, and functional consequences. Other local complications include enophthalmia and hypo- or hypercorrection. General complications may include pigmentation anomalies or infections extending as far as the orbital fat tissue. Finally, complications observed after the newer procedures of laser surgery include ectropion, burns and residual redness. Complications related to periocular injections of filling material are also mentioned. The discussion of these complications is followed by a comprehensive review of the prevention, diagnosis and management of the complications after blepharoplasty.

Aponeurotic defects and disinsertion of the levator aponeurosis are responsible for acquired involutional ptosis. The typical clinical findings in aponeurotic defects are high or moderate ptosis, good to excellent levator function, thinning of the eyelid above the tarsus, high to absent lid crease, and normal Müller's muscle function. The purpose of the treatment is to repair the defect or to advance the aponeurosis on the tarsus. This surgery can be done via the anterior approach with aponeurotic surgery or via the posterior approach with Müller's muscle conjunctival resection. In all cases, upper lid blepharoplasty is down.

Optic nerve sheath meningiomas are challenging lesions to manage. We report here a case of primary optic nerve sheath meningioma in a pregnant woman with sudden unilateral vision loss. Then we review the current literature on the subject, prognosis factors, and report the results of fractionated radiotherapy and current therapeutic guidelines. Pregnancy may accelerate growth of meningiomas and this diagnosis must be considered in all cases of optic neuropathy in pregnant woman.

Purpose: To develop a virtual model of the orbital cavity and the eyelids using a three-dimensional model., Methods: Amapi Designer 7 and Carrara 3 Studio (Eovia, Mountain View, CA, USA) software were used to obtain 3D models of the orbital cavity and the eyelids. Three-dimensional creation is divided into two main processes. In the modeling process, a 3D model of the orbit, the arterial supply, and the eyelids are created using polygonal meshes and surgical tools with parametric surfaces. In the rendering process, colors are arbitrarily chosen to make elements in the model easier to read. A virtual camera is adjusted and light sources are created to produce virtual simulations of the orbit and the eyelids., Results: Surgical techniques were illustrated with 3D models. Ptosis surgery (resection of the levator muscle and Müller's muscle conjunctival resection) and the transconjunctival approach to lower eyelid blepharoplasty were described step by step., Conclusion: Three-dimensional models have applications in many medical fields, providing representation of anatomical structures. They can be used to depict the anatomy of the orbital region in a realistic way. Three-dimensional computer-generated images are an aid in teaching residents in orbital anatomy and surgery.

Purpose: To report a patient with an adenocarcinoma in a pleomorphic adenoma of the lacrimal gland. Adenocarcinoma constitutes a distinct group of epithelial malignancies of the lacrimal gland., Methods: The clinical presentation, workup, surgical approach, and pathological findings were reviewed., Results: A 56-year-old man presented with a 3-month history of a lacrimal fossa mass. This patient presented a painless mass in the upper outer eyelid with significant displacement of the globe. The tumor was localized to the lacrimal gland. Radiological investigations showed a round, well-defined lesion in the fossa of the lacrimal gland. We performed a lateral orbitotomy; en bloc resection was accomplished. The final specimen showed an adenocarcinoma in a pleomorphic adenoma. No recurrences were detected during follow-up., Conclusion: Although adenocarcinoma has rarely been reported in association with a pleomorphic adenoma of the lacrimal gland, this combination can exist. If the malignant tumor is limited in the pleomorphic adenoma, the prognosis appears to be better than in cases of local extension. Adjuvant therapy, radiation or others, are not useful.

This review covers the techniques of reconstruction of large full-thickness defects of the lower eyelid. The authors describe tree cases of basal cell carcinoma of the lower eyelid, with large excision of the tumor. We excised the tumor and examined the edges with an extemporaneous histological exam. Reconstruction combined grafts and flaps. The advantages and disadvantages of the various techniques of lower-eyelid reconstruction are discussed.

Objective: To evaluate the results of Müller's muscle-conjunctival resection for correction of blepharoptosis and to discuss the advantages of this procedure., Methods: 38 patients (39 eyelids) were submitted to Müller's muscle-conjunctival resection. Blepharoptosis varied from 1.0 mm to 3.0 mm (mean: 2.0 mm). The amount of eyelid elevation produced by phenylephrine guided the amount of tissue to be resected., Result: 33 eyelids (85%) treated with this procedure were cosmetically acceptable., Conclusions: Müller's muscle-conjunctival resection procedure is a relatively simple technique for blepharoptosis, with good levator function and positive 10% phenylephrine test. The advantages are: preservation of tarsus and predictable results.

Graves' ophthalmopathy (GO) is a chronic autoimmune process that affects the retrobulbar tissue and has strong etiological links with graves' disease. Pathogenesis is incompletely understood. Symptoms include proptosis, extraocular muscle dysfunction, eyelid swelling and retraction. In its severe expression, it is a disfiguring and potentially sight threatening disease that profoundly influences and impairs the quality of life of affected individuals. Only a minority of patients develop severe expressions of the disease, requiring aggressive treatments. Glucocorticoids, orbital radiotherapy and decompressive orbital surgery represent a mainstay and a well established treatment for severe and active GO.

The majority of Graves' patients have mild and nonprogressive ocular involvement that does not require aggressive treatment. Local supportive measures such as wearing tinted lenses, proper eyelid hygiene, and the use of wetting agents or gels are usually sufficient to obtain symptomatic relief until eye disease becomes inactive. Smoking must be stopped and euthyroidism controlled. Management of severe forms (10% of patients) is often difficult and does not provide consistently favorable results. The use of glucocorticoids is a well-established method of treatment, indicated in severe inflammatory forms as well as in complicated forms of optic neuropathy, ocular hypertension, and corneal exposure, and are used orally or intravenously, at high doses and for prolonged periods of time. Prisms are useful in cases of diplopia. Favorable effects are reported in slightly more than 60% of cases. Glucocorticoids can be combined with orbital radiotherapy in patients with severe orbitopathy.

Orbital bony decompression has a definite place in the management of severe manifestations of dysthyroid orbitopathy such as optic neuropathy, exposure keratitis, and exophthalmos. This surgical procedure can be undertaken when medication and radiation therapy fail. Esthetic and functional results are globally satisfying and explain the interest taken in this technique. This article will describe the development of this procedure and will outline the surgical techniques and their complications. It emphasizes the multifactor indications for this procedure.

During upper blepharoplasty, myocutaneous excess and fat pads are treated using an anterior approach. Eyelid malpositions such as involutional ptosis or lid retraction could be associated and should be treated with associated procedures. Aponeurotic surgery on the levator muscle can make use of the same anterior approach, with the major difficulty of dosage. In cases of ptosis with a positive epinephrine test or minor muscular retraction, the Müller muscle-conjunctival surgery via a posterior approach seems to be more reproducible. Double-approach techniques are described.

Unlabelled: Steinert myopathic dystrophy is a generalized, hereditary disease with bone, muscular, heart and ocular involvement., Patients and Methods: This is a retrospective study of nine patients with significant blepharoptosis due to Steinert disease, who were treated at the Adolphe de Rothschild Ophthalmology Foundation over a period of 5 years. Ptosis was symmetric and major in all cases with poor levator excursion. Severity criteria were an absence of the Bell phenomenon and diminished orbicularis tone. A frontalis suspension was performed in eight cases with intentional undercorrection. The outcome was favorable in all cases, 2 with a slight overcorrection underwent a second operation, Discussion: conclusion: Surgical treatment of ptosis in Steinert disease is difficult because of a risk of lagophthalmic, keratopathy due to the severity of the disease, an absence of the Bell phenomenon and ophthalmoplegia. This surgery must be undertaken with caution, most often using a frontalis suspension. Undercorrection must be systematic, with the single goal of freeing the pupil in the primary position.

After reviewing the general principles of eyelid reconstruction, the authors present reconstruction techniques with regard to the location and size of the eyelid defect. When the defect is less than one-quarter of lid length, direct suture is possible. When the defect is larger, reconstruction techniques differ for the upper and lower lid.

Purpose: To determine the mechanisms and treatment of ocular hypertension in patients with thyroid-associated orbitopathy and to differenciate it from glaucomatous damage., Design: Three case reports., Methods: Retrospective review of clinical findings, course, and treatment of the three patients., Results: Elevated intraocular pressure in thyroid-associated orbitopathy observed in the three cases may involve different physiopathological abnormalities such as disturbances of venous circulation, compression by infiltrative muscles, and long corticosteroid use. In the first two cases, defects demonstrated in the perimetry are in consistent with glaucomatous damage. In the third case, visual field abnormalities may be compatible with a glaucomatous disease, but all defects resolved after therapy. Treatement was of the greatest difficulty for the three cases, associating antiglaucomatous medication, steroids, orbital radiotherapy, orbital decompression and extraocular muscle surgery. Intraocular pressure was controlled in all cases., Conclusions: Elevated intraocular pressure in thyroid-associated orbitopathy is distinguished from glaucomatous disease by its physiopathological mechanisms, clinical course, visual field defects, and treatment. The management of this hypertension is closely related to the treatment of dysthyroid orbitopathy.

Purpose: To evaluate the surgical technique of enucleation followed by an "on-the-table evisceration" and placement of a hydroxyapatite orbital implant wrapped by the patient's own sclera for the treatment of blind phthisis painful eyes., Patients and Methods: In this single-center retrospective study, 50 consecutive patients undergoing an operation using the same surgical technique, between April 1993 and November 1999, were studied. Patients underwent enucleation, then the eyeball was eviscerated "on the table". The patient's own cleaned sclera was used to wrap a hydroxyapatite orbital implant, the posterior pole of the sclera was placed at the anterior pole of the implant. Conjunctival breakdown, sphere size, conjunctival discharge, the first signs of sympathetic ophthalmia motility, and cosmetic results were analysed., Results: After an average follow-up of 13.3 months few complications were encountered: 4 cases (8%) of inclusion cyst and 3 cases (6%) of discharge. The implant placed had a diameter of 18 mm, 20 mm, 22 mm in, respectively, 48%, 48%, and 4% of the eyes. The prosthesis motility was good, medium, and poor in, respectively, 33 (78.6%) cases, 8 (19%) cases, and 1 (2.4%) case. The prosthesis tolerance was good, medium, and poor in respectively 86%, 10%, and 4% of the cases., Conclusion: The surgical technique of enucleation followed by an "on-the-table" evisceration and autologous sclera wrapping a hydroxyapatite implant is an easy procedure. It allows, on phthisis eyeballs, the placement of a large orbital implant for good cosmesis results, without major complications.

We report the case of a 60-year-old man presenting bilateral progressive proptosis with diplopia, weight loss, tachycardia, nervosity, and stomach pain. These signs seemed at first to favor a diagnosis of Graves'ophthalmopathy. Thyroid tests were negative and the initial orbital CT scan was considered normal. A new radiological investigation 4 months later in our hospital revealed typical hypertrophy of the extraocular muscles compatible with orbital metastasis. The systemic investigations demonstrated a pulmonary tumor, multiple hepatic lesions, and several pigmented nodules of gastric mucosa. The pathology of pulmonary and gastric specimens confirmed the diagnosis of malignant melanoma. The primary lesion remains unknown. The authors discuss the differential diagnoses of orbital metastasis and the radiological characteristics of orbital metastasis in malignant melanoma.

Tearing in infants and young children is a subject of controversy. A logical succession of questions and answers is helpful in developing a consensual attitude.

Dysthyroid exophthalmos is due to mismatching of the orbit and its contents, essentially due to muscle enlargement, and, to a lesser degree, fat volumetric changes. Surgical treatment is designed to expand the orbital volume by bone removal or to reduce orbital contents by fat removal, or a combination of the two techniques. Our series consisted of 69 patients who underwent orbital decompression for proptosis, with osteotomy (12 cases) or associated with fat removal (57 cases). We obtained good results for all cases, and did not encounter any complications. Several factors now appear to play a role in the choice of surgical technique, particularly the preoperative radiologic (CT) examination which determines the muscular and fat involvement, wall orbital changes and appearance of the sinuses. Orbital fat removal seems to be useful in proptosis reduction in those cases in which fat is more involved and easy to remove. Anthral ethmoidal decompression is the best technique in the case of dysthyroid optic neuropathy.

Purpose: To report the prevalence and visual outcome of macular pucker occurring after retinal detachment surgery, and to analyze its risk factors., Methods: We retrospectively studied 865 cases of retinal detachment that had been successfully treated in the absence of macular hole or proliferative vitreoretinopathy higher than grade C1. For the statistical analysis, 63 variables were submitted to CHI-square test., Results: Macular pucker occurred in 68 cases (7.7%). Final visual acuity was 0.5 or better in 24 cases, spontaneously in 7 and after macular surgery in 17. In 6 other cases, macular pucker was much less important in terms of visual impairment than coexisting amblyopia or other posterior pole pathology. In the 38 remaining cases, macular pucker was the cause of visual failure, despite macular surgery in 9 of them. Retinal detachment recurred after macular surgery in 2/26 cases. Nine variables were found to correlate with an increased risk of macular pucker: emmetropia, hyperopia, preoperative acuity reduced to light perception-hand movement, macula off, preoperative proliferative vitreoretinopathy (grade B or C1), retinal tears up to 30 degrees, retinal tears larger than 30 degrees, and cumulative retinal break area larger than 3 disks., Conclusion: Our results show that macular surgery can be useful in case of macular pucker after retinal detachment surgery. They also suggest that macular pucker and proliferative vitreoretinopathy have some risk factors in common.

Purpose: Congenital lid ectropion is a rare anomaly. In the usual classification, primary ectropion caused by tightening of the anterior lamella may sometimes be confused with secondary ectropion, especially with blepharophimosis syndrome or euryblepharon., Methods: Through analysis of two representative cases of congenital ectropion and review of literature we discuss similarities and differences between primary and secondary ectropion including blepharophimosis and euryblepharon., Results: Horizontal narrowing of palpebral fissure and inversus epicanthal folds are the main clinical feature to be considered when differential diagnosis is difficult between primary forms and blepharophimosis, as ptosis is often an underlying abnormaly in both cases., Conclusion: To be effective, the surgical management of congenital lid ectropion requires precise clinical examination, clear understanding of causative factors and several procedures.

Post-traumatic ptosis may be classified as follows: ptosis occurring during lid avulsion, ptosis associated with fractures of the orbital roof and with foreign bodies, post-contusional ptosis, cicatricial ptosis, neurogenic ptosis and post-surgical ptosis. The patient must be thoroughly examined, including examination of the eye-ball, extra-ocular muscles, eyelid and evaluation of upper eyelid levator function and orbital and facial examination. The various surgical methods proposed include levator muscle surgery, aponeurotic surgery, Müller's muscle surgery and frontalis suspension surgery. Surgical indications and choice of surgical method essentially depend on the anatomo-clinical forms. The general rule is to operate under local anesthesia to obtain better control of the muscular function. Some cases are simple to treat such as post-contusional ptosis with good levator function which allows functional surgery with excellent static and dynamic results. Other relatively simple cases with non functional levators may only be treated on a static basis. Last but not least are more difficult cases in which levator function is difficult to evaluate pre-operatively because of severe fibrosis. The aim in such cases is to explore the eyelid by an anterior approach under local anesthesia and to propose either muscular surgery or a frontalis suspension according to the anatomical and functional status of the levator muscle.

Colobomatous orbital cyst with microphthalmos is an anomaly of the orbital contents occurring during embryogenesis. In this study, we report the case of a 3 year-old child referred with the initial diagnosis of voluminous orbital angioma. Radiological investigations and histological study of the ablated mass established the correct diagnosis of colobomatous cyst. Pathogeny, diagnostic and therapeutic problems are discussed.

A three-year-old girl presented a voluminous capillary haemangioma associated with amblyopia. This case failed to respond to steroid treatment. Surgical treatment was necessary. The authors describe evolution, complications and therapeutic management of eyelid angiodysplasia.

Lubboc (T650) is a bovine heterologous bone implant obtained by specific preparation of trabecular of bone. In vitro and in vivo biocompatibility studies have revealed the absence of any cytotoxicity or systemic toxicity. Lubboc has many fields of application, including all bone graft surgical indications. We report our first results concerning the use of this product in orbital surgery either as a filling or contention material or as an apposition material. On all 20 operated patients we did not encounter any intolerance, inflammation or infection. The follow-up is still too short to appreciate the long term integration of this material which has the advantage of being a substitute for autologous bone, avoiding bone graft harvesting.

Twenty cases of severe progressive ophthalmoplegia (Myopathic ptosis) with significant ptosis were treated by various procedures, including levator resection with blepharoplasty or frontalis suspension using temporalis fascia. Surgical indications were generally limited to cases with poor or absent levator function. The results are analysed after an average follow-up of 6 months. The particular problems concerning surgery of myopathic ptosis are discussed.