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Purpose: To evaluate the outcome of surgical excision of large and massive orbital tumors. To the best of our knowledge, this is the first article to evaluate the relationship between the size of orbital tumors and the surgical outcome. Methods: We retrospectively reviewed the charts of 34 consecutive patients affected by large or massive orbital tumors that underwent orbitotomy with en-bloc excision of the lesion. The main outcome measures included visual acuity, visual field testing, extraocular motility, pupillary function, and Hertel exophthalmometry readings. Follow-up time ranged from 1 to 4 years. Results: Complications of the surgical intervention included 1 patient with visual loss (2.9%), 2 patients with third nerve palsy (5.8%), and 6 patients with de novo strabismus (17.6%). In this setting, enophthalmos was an expected outcome more than a true complication and occurred in 5 patients (14.7%). Conclusions: Although this is a relatively small and retrospective series, these findings suggests that the surgical excision of large and massive orbital tumors carries significant risks of surgical complications including visual loss, enophthalmos, strabismus, and third nerve palsy. These complications may occur as consequence of excessive traction, reduced working room, blind dissection behind the increased bulk of the tumor, or release of tight adhesions between the tumor and the surrounding orbital structures.

The use of orbital fat pedicles as a filler is gaining in popularity. The use of fat transposition can be incorporated with both transcutaneous and transconjunctival approaches to the lower eyelid. In either case, a preseptal approach is utilized to expose the arcus marginalis along the entire inferior orbital rim. Tisseel (fibrin sealant) (Baxter Corporation, Ontario, Canada) is used to secure the fat into position. Hemostasis is confirmed within the subperiosteal pocket.

Understanding aging changes of the midface is necessary to address the functional and aesthetic concerns of our patients. With age, the malar fat pad descends and overlaps the relatively fixed nasolabial fold causing it to deepen. Above the fat pad the arcus marginalis and orbital septum limit descent of the orbital fat. As the cheek descends, a division develops between the eyelid and malar fat pad. These hollows cause shadowing beneath the eye, creating a tired and aged appearance. With further ptosis of the midface, the eyelid skin becomes distracted inferiorly. Combining this with horizontal laxity of the eyelid can result in significant ectropion. Standard aesthetic techniques for lower face lifting generally do not adequately address the changes in the midface.

Upper eyelid blepharoplasty is one of the most common facial aesthetic procedures performed today. Then surgery is performed for both functional and aesthetic purposes by surgeons from a number of different subspecialties. As the surgery involves one of our most important sensory organs, the eye, a detailed understanding of relevant anatomy, operative technique, and potential risks is paramount. With this in mind, the procedure is generally safe, effective, and reliably reproducible when experience is gained. To attain these kinds of results, care and attention must be given to patient selection, expectations, the preoperative evaluation, the surgical technique, and to postoperative care. Complications are usually mild and self-limiting and can be addressed with conservative measures and reassurance.

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.

A chief morbidity of facial nerve palsy is ocular exposure, which is largely due to lower lid retraction and ectropion.To assess the role of midfacial elevation in the comprehensive surgical treatment of paralytic lower lid malposition and ocular exposure.Eleven patients with chronic facial nerve palsy causing symptomatic ocular exposure were treated with subperiosteal midface elevation as a component of comprehensive lower lid elevation. Other procedures were performed concomitantly to treat lower lid ligament laxity and reduced lower lid rigidity, as required. Preoperative and postoperative ocular exposure symptoms, visual acuity, lower lid position, lagophthalmos, and keratopathy were compared.At an average of 17 months of follow-up, all patients reported improvement in symptoms. Visual acuity was maintained or improved in all patients. Lower eyelid position (P =.003), lagophthalmos (P =.07), and keratopathy (P.001) were also improved.Midfacial elevation is a safe and effective surgical adjunct in the treatment of lower eyelid retraction in chronic facial palsy. Its use reduces the need for tarsorrhaphy, which limits the binocular visual field and negatively impacts cosmesis.

A 45-year-old man and a 21-year old man presented with palpable lacrimal gland fossa masses and mechanical ptosis and proptosis, respectively. Computed tomography demonstrated well-circumscribed, partially cystic tumors. Echography in one case showed a well-outlined, predominantly low-reflective lesion with cysts and moderate vascularity detected by Doppler flow and standardized A-scan studies. Histopathology of the excised tumors revealed them to be CD34 antigen-positive hemangiopericytomas, in one case associated with lacrimal gland ductal cysts (dacryops) and with cyst-like spaces containing proteinaceous exudate in the other. No recurrence was found at 14 and 30 months, respectively. Although uncommon, hemangiopericytomas should be included in the differential diagnosis of lacrimal gland tumors. Orbital ultrasound revealing vascularity may be a useful adjunct in this diagnosis. Cystic degeneration or dacryops due to tumor infiltration and compression of lacrimal gland ducts may occur.

Purpose: An experimental study was performed to: 1) assess the tolerance and incorporation of porous polyethylene (Medpor) in the posterior lamella of the rabbit lower eyelid; 2) analyze the effect of implant thickness on incorporation; 3) investigate the ability of conjunctiva to grow over vascularized Medpor and; 4) determine the effects of Medpor surface modification on biocompatibility and fibrovascularization. Methods: In phase I, 10 rabbit eyelids were operated on to analyze the effects of implant thickness and to develop the surgical technique used in phase II of the study. In phase II, 20 lower eyelids of 10 rabbits received 0.85-mm-thick Medpor grafts, each rabbit receiving both an uncoated implant and one coated with an immobilized collagen. Results: There were no extrusions in phase II. with a postoperative follow-up from 14 to 17 weeks. Fourteen of 20 eyelids had full-thickness conjunctival incisions or excisions placed over the Medpor implant to determine the growth potential of conjunctiva over a vascularized implant. All but one eyelid showed complete defect coverage, occurring in as little as 3 days. Histopathology indicated complete Medpor fibrovascularization as early as 4 weeks after implantation. Because neither coated nor uncoated implants extruded in phase II, no conclusions can be drawn regarding the efficacy of Medpor surface modification. Conclusion: Medpor was well tolerated in this soft tissue application, and it offers advantages over other graft materials.

Summary We report a woman who had a recurrent trichofolliculoma on the upper eyelid margin. Only three cases of this benign tumor on the eyelid have been reported, and no recurrence in this location had been noted in the literature. The lesion, present for 6 years, had been excised twice previously (3 and 4 years before), recurred, and had been injected with a steroid preparation 2 years earlier. Lashes, both normal-looking and immature, arose from the center area of this lesion, and telangiectatic vessels were on its surface. Full-thickness wedge resection was used to excise the lesion completely. Complete primary excision of trichofolliculoma is important, and local steroid preparations should not be used.

Malignant peripheral sheath tumor (malignant PNS tumor) is a rare, aggressive, and lethal orbital neoplasm that usually arises from sensory branches of the trigeminal nerve in adults. Malignant PNS tumor spreads along nerves to involve the brain, and most patients die within 5 years of clinical diagnosis. The clinical history and examination, imaging studies, surgical procedures, and pathologic specimens of a 23-year-old man with rapid, posttraumatic onset of left orbital proptosis and pain are reported. Biopsy specimens of the tumor were compared with specimens from the same orbit obtained 18 years previously. Histopathology of the left orbital tumor compared with that of an incomplete excision of a tumor 18 years previously in the same orbit revealed both to be malignant PNS tumor. The patient is alive without recurrence 8 months after orbital exenteration and 18 years after initial tumor presentation. This is the youngest age of occurrence and the longest documented survival of a patient with orbital malignant PNS tumor.

To evaluate the long-term efficacy of transcaruncular medial canthal ligament (MCL) plication in the treatment of eyelid malposition.Transcaruncular MCL plication was performed on 176 eyelids of 125 patients with symptomatic ocular exposure due to lower eyelid malposition in which MCL laxity was an important component. Preoperative and postoperative ocular exposure symptoms, lower eyelid position, lagophthalmos, and keratopathy were compared.At an average +/- SD follow-up time of 25 +/- 27 months (range, 1-103 months), 88% of preoperative symptoms resolved or improved. Lower eyelid position (P.001), lagophthalmos (P.001), and keratopathy (P.001) were significantly improved. In 11% of eyelids undergoing MCL plication as the only repair, results were comparable with those in which other repairs were performed concurrently. Complications were suture breakage in 2 cases and pyogenic granuloma in 1 case.Transcaruncular MCL plication is a safe and effective technique for MCL laxity that contributes to lower eyelid malposition. This minimally invasive technique achieves good functional and cosmetic outcomes by re-establishing the vectoral forces for eyelid support that are normally provided by the tripartite ligament.

Objectives: To define the lateral extension of the Muller muscle and to elucidate its involvement in the development and surgical treatment of Graves (thyroid) eye disease. Methods: Twelve lateral halves of orbits exenterated from patients with medial or posterior orbital neoplasms were fixed, embedded, and step sectioned at 250-μm intervals to produce histological sections. Gross anatomical dissections of human cadaver heads were also used to corroborate the histological findings. Results: Histological analysis revealed that the Muller muscle extended laterally between the orbital and palpebral lobes of the lacrimal gland in all specimens. The smooth muscle fibers were found to interdigitate with lacrimal ducts passing from the orbital to palpebral lobe and to extend close to the ductal orifices at the conjunctival surface. Gross dissections confirmed that the Muller muscle accompanied the levator aponeurosis lateral extension, which is known to pass between the orbital and palpebral lobes of the lacrimal gland. Conclusions: Our anatomical findings suggest that the Muller muscle may contribute to the temporal flare frequently seen in eyelid retraction associated with thyroid eye disease. They may also explain the difficulty of treating lateral eyelid retraction in thyroid eye disease and indicate the need for new surgical approaches for severe lateral eyelid retraction.