Faculty Bibliography

PURPOSE/OBJECTIVE:To measure orbital cavernous hemangioma size using 3 segmentation methods requiring different degrees of subjective judgment, and to evaluate interobserver agreement using these methods. METHODS:Fourteen patients with orbital cavernous hemangiomas were included in the study. Pretreatment T2-weighted MRIs were analyzed by 2 observers using 3 methods, including 1 user-dependent image segmentation method that required high degrees of subjective judgment (ellipsoid) and 2 parameter-dependent methods that required low degree of subjective judgment (GrowCut and k-means clustering segmentation). Interobserver agreement was assessed using Lin's concordance correlation coefficients. RESULTS:Using the ellipsoid method, the average tumor sizes calculated by the 2 observers were 1.68 ml (standard deviation [SD] 1.45 ml) and 1.48 ml (SD 1.19 ml). Using the GrowCut method, the average tumor sizes calculated by the 2 observers were 3.00 ml (SD 2.46 ml) and 6.34 ml (SD 3.78 ml). Using k-means clustering segmentation, the average tumor sizes calculated by the 2 observers were 2.31 ml (SD 1.83 ml) and 2.12 ml (SD 1.87 ml). The concordance correlation coefficient for the ellipsoid, GrowCut, and k-means clustering methods were 0.92 (95% CI, 0.83-0.99), 0.12 (95% CI, -0.21 to 0.44), and 0.95 (95% CI, 0.90-0.99), respectively. CONCLUSIONS:k-means clustering, a parameter-dependent method with low degree of subjective judgment, showed better interobserver agreement compared with the ellipsoid and GrowCut methods. k-means clustering clearly delineated tumor boundaries and outlined components of the tumor with different signal intensities.

Purpose/UNASSIGNED:and describe its clinical and histopathological features. Findings/UNASSIGNED:involvement. Histopathological analysis demonstrated fulminant polymorphonuclear infiltration of all ocular tissue layers. Despite aggressive management including two intravitreal injections and enucleation, the patient died, ultimately after receiving care at four neighboring urban medical centers. Conclusions and importance/UNASSIGNED:. A high suspicion of its contribution to panophthalmitis could be warranted early in the evaluation and management of profoundly immunocompromised patients, particularly those who have had sequential care at multiple neighboring metropolitan hospitals.

Extraocular muscle (EOM) entrapment with resulting reduction in motility and diplopia is a known complication of orbital fractures. Less commonly, transection of the EOMs due to trauma, iatrogenic injury, or intentional myotomy may lead to persistent diplopia. The inferior oblique (IO) is often encountered during orbital surgery along the medial wall and floor, and may be disinserted to aid in visualization. The authors present a case of IO entrapment which occurred during zygomaticomaxillary fracture reduction. Intraoperatively, an IO transection was performed and the muscle was reattached within the orbit. Postoperatively, the patient did not develop diplopia or motility disruption. This technique may provide a useful solution to an unusual problem during orbital fracture repair.

Orbital dermoid cysts are fairly common and arise by sequestration of surface ectoderm along skeletal suture lines during embryologic development. Although anterior dermoid cysts are generally evident in infancy, deeper cysts typically present with inflammatory symptoms in adulthood. The authors report the clinical and imaging features for 6 cases of deep orbital dermoid cysts that were identified by the presence of subconjunctival lipid droplets; to the authors' knowledge, this case report represents the largest series of dermoids with such a presentation. In the absence of prior vitreoretinal surgery, subconjunctival lipid droplets are an important clinical sign suggesting the presence of a deep orbital dermoid cyst.

Purpose : To describe clinical features requiring urgent surgical intervention for superior orbital blow-in fractures with and without globe compression. Methods : Retrospective, consecutive case series between 6/1/2018 and 12/1/2019. Results : Six patients (6 eyes) with superior orbital blow-in fractures were identified, 50% with bone fragments compressing the globe. The mean age of presentation was 31.8 +/- 10.5 years. The majority of patients were male (83%), involved the left eye (83%), and were assault victims with a swinging object (50%). All patients had periorbital edema and a brow laceration. No patients had clinical evidence of a ruptured globe. The visual acuity of the affected eye ranged from 20/20 to 20/30. Post-operative visual acuity worsened in one case (16%) due to vitreous hemorrhage. Surgical approaches included lateral orbitotomy through the brow laceration (66%), through an eyelid crease incision (17%) and a craniotomy (17%). The most common fracture types on computed tomography included communicated fractures of the frontal sinus to the superior orbital rim (83%), involvement of the zygomatic bone (33%) and an inferiorly displaced superior orbital rim (17%). Additional orbital injuries included left rectus hematoma (16%), bone fragment abutting the lacrimal gland (50%) and intraconal hematoma (33%). An intracranial injury was seen in 33% of patients, including a parieto-occipital hematoma and frontal white matter contusion. Fifty percent of patients had bone fragments directly compressing the globe with deformation of the globe contour, which was visible on fundoscopic examination and bedside ocular ultrasound. Distinguishing features of orbital blow-in fractures with globe compression compared to those without included supra-and abduction motility deficits, proptosis, globe dystopia and abnormal posterior segment exam, which were seen in all cases. Posterior segment findings included choroidal folds (100%), choroidal rupture (33%), commotio (33%) and vitreous hemorrhage (33%), however there were no retinal tears or detachments. Conclusions : In cases of periocular trauma, the presence of exophthalmos, globe dystopia, ocular motility deficits, and choroidal folds may suggest an orbital blow in fracture with globe compression. These findings should prompt expedited imaging and surgical intervention when appropriate

A 22-year-old Hispanic man with sickle cell trait presented with blurred vision, double vision, and pain with OD movement. MRI demonstrated an extra-axial mass centered around the temporal bone with extension into the middle cranial fossa and lateral aspect of the extra-conal right orbit, and mass effect on the lateral rectus muscle. Biopsy of the lesion was consistent with renal medullary carcinoma. CT chest/abdomen/pelvis confirmed a primary tumor in the right kidney. No additional metastases were found. Renal medullary carcinoma is a rare, highly aggressive malignancy, which almost exclusively affects young men of African descent with sickle cell trait or sickle cell disease. The authors present the second confirmed case of renal medullary carcinoma metastatic to the orbit, with ocular symptoms prior the typical presenting symptoms of flank pain and hematuria.

A 22-year-old female presented for evaluation of five years of progressive left exophthalmos and intermittent blurred vision. She had previously received laser treatment for peripheral retinal neovascularization and had undergone lip reconstruction for a left-sided congenital vascular facial malformation. Magnetic resonance imaging demonstrated diffuse enlargement of the left extraocular and temporalis muscles, with prominent vessels in the temporalis muscle and intraconal fat. Left fundoscopic examination revealed grossly enlarged, tortuous retinal vessels extending from the optic disc to the peripheral retina and an abnormal network of capillaries. On the basis of these findings, a diagnosis of retinoencephalofacial angiomatosis was established. Retinoencephalofacial angiomatosis is a rare, non-hereditary disorder associated with ipsilateral retinal, brain, and facial arteriovenous malformations. This is the first report, to the authors' knowledge, of retinoencephalofacial angiomatosis presenting with exophthalmos secondary to extraocular muscle enlargement.

PURPOSE/OBJECTIVE:To investigate the safety and efficacy of direct, intralesional doxycycline hyclate injection for improving the appearance of cosmetically significant lower eyelid festoons and malar edema. METHODS:An Institutional Review Board approved, retrospective review was performed of 15 consecutive patients with malar edema and/or festoons injected with doxycycline hyclate at a concentration of 10 mg/ml. Pre- and postinjection photographs were reviewed and graded on a scale of 0 to 3 (0: no festoon; 1: small festoon; 2: medium festoon; 3: large festoon) by 2 masked physician observers. Patients were excluded from the final analysis if they received an alternate dose concentration, had incomplete photographic records, or did not follow up. Student t test was used for statistical analysis. RESULTS:Twenty consecutive treatment areas of 11 patients were included in the analysis. Final follow up ranged from 3 to 104 weeks, with a mean follow up of 22.5 weeks. The average (standard deviation) initial festoon grade of 2.5 (0.58) decreased to 0.9 (0.82) with a p value of <0.001. The average number of injections performed per side was 1.4 (range: 1-2). The mean volume per injection was 0.72 ml (range: 0.15-2.0 ml). Commonly documented subjective complaints were burning sensation with injection, pain, bruising, and erythema. There were no other dermatologic or visual complications following treatment. CONCLUSIONS:These preliminary results suggest that intralesional injections of doxycycline hyclate at a concentration of 10 mg/ml may be an effective treatment option for cosmetically significant lower eyelid festoons and malar edema. Future prospective studies with increased patient numbers, increasing concentrations, combination therapies with local anesthetic or regional nerve blocks, and longer follow up are needed to validate these results and determine optimal injection technique.