Faculty Bibliography

PURPOSE:: To describe a case series of ointment granuloma as a complication of sutureless transconjunctival blepharoplasty. METHODS:: A retrospective review of the medical records of 8 patients with this complication was conducted, including the histopathology of excised tissues. Institutional review board oversight was waived as this was not an institutional study but a Health Insurance Portability and Accountability Act-compliant retrospective chart review from the private medical practice of one of authors' coauthors. It adhered to the principles set forth in the Declaration of Helsinki. RESULTS:: Eight patients developed painless lower eyelid and anterior orbital masses following presumed successful blepharoplasty. Each had received intra- or immediate postoperative lubricating ointment. The mean time from surgery to appearance of the lesions was 50 days (range: 9 days-10 months). Three patients responded to intralesional injection of steroid with complete resolution. Five patients required surgical excision of the lesions without recurrence to date. Histopathological examination of the excised tissues revealed large, pleomorphic lipid-dropout pools bordered by attenuated histiocytes and giant cells. CONCLUSIONS:: The appearance of eyelid lumps or fullness in the early and mid-postoperative recovery should suggest ointment granuloma. If recognized early, management should commence with intralesional injection of steroids, although the definitive treatment is surgical excision. The authors recommend minimizing the access of topical ointments to the open inferior fornix, placing the medication sparingly onto the cornea at the close of surgery and instructing patients in avoiding overuse.

PURPOSE: To describe a patient with severe ischemic retinopathy and maculopathy in the context of neurofibromatosis Type 1. METHODS: Case report illustrated with multimodal clinical imaging. A 16-year-old female with neurofibromatosis Type 1 presented with visual deterioration over several weeks. Her right eye was amblyopic because of an optic nerve glioma treated in childhood with chemotherapy. RESULTS: Corrected visual acuities were counting fingers in the right eye and 20/150 in the left eye. Examination revealed bilateral optic disk pallor. In the left eye, severe and extensive ischemic retinopathy and maculopathy were noted with collateral formation and neovascularization. Proximal arterial occlusion at the level of the internal carotid and ophthalmic arteries was excluded on neuroimaging, including computed tomography angiography. CONCLUSION: Neurofibromatosis Type 1 may present in the ocular fundus with a variety of lesion types, including vasoproliferative tumors, hamartoma, uveal melanoma, and hemangioma. Vascular occlusions are relatively uncommon. Ocular ischemic syndrome secondary to moyamoya syndrome is well described in neurofibromatosis Type 1 but was excluded in our patient. A spectrum of retinal microvascular abnormalities has also been described, but disease-specific evidence to guide treatment is lacking.

Purpose: To analyze the surgical management and outcomes of patients with canalicular lacerations and to report the epidemiological data and clinical characteristics of this group of patients. Methods: A retrospective review of medical records of all patients with canalicular lacerations from 1992 to the present at a single institution. Results: A total of 50 patients with injury to the canalicular system were identified, mean age 32 years (range 16 months - 88 years), 82% were male and 18% female. 82% were adult and 18% were pediatric patients. The most common mechanism of injury in adults was assault (50%) while in children it was accidents with objects (33%). 86% were found to have injury to one canaliculus while 14% had a bicanalicular laceration. 68% of the canaliculi injured were lower lid, 32% were upper lid. 78% of the lacerations were graded as mild or moderate and 22% were severe, with associated medial canthal avulsion or extensive globe or orbital injury. 94% proceeded to repair within 48 hours; in two patients, canalicular intubation could not be achieved intraoperatively. Of the 48 patients who underwent surgical repair, 22% had monocanalicular intubation with the Mini-Monoka and 78% percent had repair with the Crawford tube. All (100%) bicanalicular lacerations were repaired with the bicanalicular Crawford tube. The majority of monocanalicular lacerations (78%) were repaired with either the monocanalicular or bicanalicular Crawford tube; all (100%) of the lacerations repaired with the Mini-manoka were mild. Thirty patients had follow up beyond post-operative month 1, with an average follow-up of 6 months. The average length of intubation was 5.7 months. 93% of patients had successful functional and anatomic outcomes. The most common complication was tube extrusion requiring repositioning or repeat surgery, which occurred at the same rate (17%) with the Mini-Monoka and Crawford tube. In two such instances, one type of stent was replaced for another secondary to patient anatomy. Conclusions: In our experience, most canalicular lacerations are sustained by adult males and are related to assault. The majority of canalicular lacerations are repaired with bicanalicular Crawford tubes within 48 hours. Both methods of repair, Mini Monoka stent and Crawford tube, are effective in achieving good outcome and it is important to be familiar with the use of both

Abstract Purpose: To describe the location of the zygomatico-orbital foramen on the inferolateral orbital wall. Methods: This anatomic study examined 28 orbits of 14 dry human adult skulls. The zygomatico-orbital foramen was identified by passing a thin wire from the zygomatico-facial foramen to its orbital aspect and a thin flexible ruler was used to measure 1) the distance perpendicular to the closest point on the inferior orbital rim, 2) the distance from the inferior orbital fissure, and 3) the distance from the area used for retrobulbar injections. Results: The mean distance from the zygomatico-orbital foramen to the closest point on the inferior orbital rim was 4.7 mm (range from 1 to 7 mm). The mean distance from the inferior orbital fissure was 14.9 mm (range from 10 to 18 mm). The mean distance from the area of retrobulbar injection was 6.0 mm (range from 3 to 10 mm). Conclusions: The location of the zygomatico-orbital foramen within the inferolateral orbit is quite variable. This is the first study to attempt to quantify its proximity to the site of retrobulbar injection. We conclude that it is an important anatomical structure to consider when giving retrobulbar anesthesia, especially given the variability in technique among ophthalmologists.

PURPOSE: To evaluate conjunctival nevi using anterior segment optical coherence tomography (AS-OCT). DESIGN: Retrospective interventional case series. PARTICIPANTS: There were 22 eyes of 21 patients with conjunctival nevus imaged with AS-OCT for evaluation and detection of cysts within conjunctival nevi. INTERVENTION: Anterior segment OCT. MAIN OUTCOME MEASURES: Evaluation and detection of intralesional cysts. RESULTS: All margins of the nevus, including the deep margin, could be visualized on AS-OCT with high resolution of the anterior margin in 100% of cases, posterior margin in 82% of cases, and lateral margin in 86% of cases. The nevus was optically dense with homogeneous pattern in all cases. Some degree of deep optical shadowing, mostly from pigmented nevi, was noted in 86%. Intrinsic cysts within the nevus were detected by slit-lamp biomicroscopy in 18 cases (82%) and by AS-OCT in 17 cases (77%). In comparison with histopathologic findings, AS-OCT detected intrinsic cysts with a sensitivity of 80%, specificity of 100%, positive predictive value (PPV) of 100%, and negative predictive value (NPV) of 60%. Slit-lamp biomicroscopy (by experienced observers) compared with histopathology revealed detection of cysts with a sensitivity of 100%, a specificity of 100%, a PPV of 100%, and an NPV of 100%. CONCLUSIONS: Anterior segment OCT provides high-resolution imaging of conjunctival nevi with the ability to demonstrate all margins and to provide information on the presence of intralesional cysts, which are important in the diagnosis. The main drawback is optical shadowing of deeper structures from pigment within nevi.

PURPOSE: To evaluate prognostic factors based on origin of conjunctival melanoma. DESIGN: Interventional case series. PARTICIPANTS: Three hundred eighty-two consecutive patients. METHODS: Retrospective chart review. MAIN OUTCOME MEASURES: Melanoma-related metastasis and death. RESULTS: The melanoma arose from primary acquired melanosis (PAM; n = 284; 74%), from pre-existing nevus (n = 26; 7%), and de novo (n = 72; 19%). The mean tumor base was 11 mm for melanoma arising from PAM, 6 mm for melanoma arising from nevus, and 10 mm for those arising de novo. At 5 years (10 years), melanoma metastasis occurred in 19% (25%) in melanoma arising from PAM (P = 0.003), 10% (26%) in melanoma from nevus (P = 0.193), and 35% (49%) in those de novo. Factors predictive of metastasis by multivariable analysis included tumor origin de novo (P = 0.001), palpebral location (P<0.001), nodular tumor (P = 0.005), and orbital invasion (P = 0.022). At 5 years (10 years), melanoma-related death occurred in 5% (9%) in melanoma arising from PAM (P<0.001), 0% (9%) in melanoma arising from nevus (P<0.057), and 17% (35%) in those arising de novo. Factors predictive of death by multivariable analysis included tumor origin de novo (P<0.001), fornix location (P = 0.04), and nodular tumor (P = 0.001). CONCLUSIONS: Melanoma arising de novo carries a higher risk of melanoma-related metastasis and death compared with those cases arising from PAM or nevus.