Ocular Adnexal Structures Research Articles

Lymphoma involvement of the eyelid and eye

Lymphomas of the eye and ocular adnexa are rare lymphoproliferative diseases of the ocular and ocular adnexal tissue. The incidence of these diseases has been rapidly increasing over the past few decades. The exact pathogenesis remains unknown, but it is postulated to be multifactorial and includes genetic aberrations, epigenetic and environmental factors, infectious agents, and chronic antigenic stimulation. The majority of ocular and ocular adnexal lymphomas are of B-cell origin, except for eyelid lymphomas, which are more often of T-cell type. Lymphoproliferative diseases of ocular and ocular adnexal structures are either primary, when they arise in the eye, orbit, lacrimal gland, eyelid, and/or conjunctiva, or secondary extranodal manifestation of systemic lymphoma. Diagnosis is challenging and requires a multidisciplinary approach involving ophthalmologists, dermatologists, oncologists, and radiation oncologists.

Fulminant orbital cellulitis with compartment syndrome and vision loss due to streptococcus pyogenes: A case report

: To describe an unusual case of fulminant orbital cellulitis with complete vision loss despite timely medical and surgical management. Orbital cellulitis is an infective condition of the ocular adnexal structures (fat, periorbita, and muscles) behind the orbital septum. A 22-year-old female presented with rapidly progressing orbital cellulitis and was started on empirical intravenous antibiotics. Orbital imaging showing marked proptosis with optic nerve stretching and an extraconal abscess in the medial aspect of left orbit. Emergency lateral canthotomy and orbital decompression was done. Streptococcus pyogenes was isolated on culture and antibiotics changed according to the sensitivity pattern. Lid edema, proptosis, and extraocular movements improved but vision deteriorated to absent light perception. Fundus showed disc pallor on follow up. A case of fulminant orbital cellulitis with compartment syndrome and ischemic necrosis of optic nerve is reported, which led to permanent vision loss despite timely antibiotics and surgical management.Despite prompt surgical intervention and administration of intravenous antibiotics, the patient may develop compartment syndrome, ischemic necrosis or infiltration of the optic nerve leading to complete vision loss.Orbital cellulitis is an infective condition of the ocular adnexal structures (fat, periorbita, and muscles) behind the orbital septum. This condition is more common in children and young adults and usually results from a paranasal sinus or any facial infection. The majority of the organisms isolated are Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae B and Moraxella catarrhalis. Beta-hemolytic streptococci are rarely implicated. Bacterial cellulitis usually responds well to antibiotics but rarely may result in vision or life-threatening complications.

A complicated case of orbital cellulitis: When the fog doesn't clear.

Orbital cellulitis is a potential sight-threatening infection of the ocular adnexal structures posterior to the orbital septum. Acute bacterial sinusitis remains the most common cause of orbital cellulitis in the paediatric age group. Simultaneous intracranial and orbital complications from orbital cellulitis are rare. We describe a case of orbital cellulitis, which proceeded to sub-periosteal abscess formation and intracranial abscess within days of the initial presentation. The specific features of this case including the rapid progression of the orbital inflammation, failure of improvement over 48 h despite maximal medical treatment and incorrect initial reporting of computed tomography imaging all contributed to the complications seen in this case.

Ocular Adnexal Infections

The lacrimal gland and the nasolacrimal excretory system (canaliculus, nasolacrimal sac, and nasolacrimal duct), the extraocular muscles, the eyelids, eyelashes, eyebrows, and the conjunctiva comprise the ocular adnexal structures. Infections affecting these tissues represent a major cause of annual ophthalmology visits, a significant cause of morbidity, and healthcare cost. The purpose of this report is to critically review and evaluate the literature published over the past year pertaining to ocular adnexal infections. However, an update on microbial resistance precedes any discussion of infectious diseases. Sotonzono et al. reported cases of methicillin-sensitive and methicillin-resistant Staphylococcus aureus (MSSA, MRSA, respectively) refractory to fluoroquinolone therapy may be treated with 1 % vancomycin ointment [1]. The staphylococcal ocular adnexal infections included conjunctivitis, blepharitis, meibomitis, dacryocystitis, or keratitis. However, the study was small (25 patients) and adverse reactions to the vancomycin ointment occurred in 28 % of patients (7/28) and included eyelid edema and conjunctival hyperemia. Nonetheless, the importance of new antibiotics and formulations becomes clear, when one considers the emergence of antibiotic-resistant microorganisms and our obligation to prescribe antibiotic therapy responsibly. Another study examined culture and sensitivity results obtained from ocular and ocular adnexal infections over a 4-year period in order to trend the emergence of levofloxacin resistance [2]. These infections ranged from orbital cellulitis, blepharitis, dacryoadenitis, conjunctivitis, infectious corneal ulcer, and endophthalmitis, and of the 242 cases reviewed, levofloxacin-resistant strains occurred in 32.8 % of isolates. These data raise awareness of resistance to this fluoroquinolone and a possible future increase in levofloxacin-resistant ocular and ocular adnexal infections. Although no cases of vancomycin-resistant strains were reported, the authors advocate using this antibiotic only, when absolutely necessary to prevent the emergence of vancomycin resistance. Several antibiotic trials for the treatment of conjunctivitis were published over the past year. Malamos et al. showed single-dose oral azithromycin to be an effective alternative to combined oral azithromycin/doxycycline therapy in the treatment of adult inclusion conjunctivitis [3]. Topical azithromycin 1.5 % ophthalmic solution was shown to provide a more rapid resolution than tobramycin 0.3 % ophthalmic solution in the treatment of purulent bacterial conjunctivitis in children, with a more convenient twice-a-day dosing regimen [4]. A randomized control trial comparing polymyxin B-trimethoprim to moxifloxacin showed equal response rates in purulent conjunctivitis in pediatric patients and offered significant cost saving compared to moxifloxacin [5]. Finally, besifloxacin 0.6 % ophthalmic solution three times daily for 7 days was shown to be safe in patients aged 1 year and older for bacterial conjunctivitis [6, 7]. Conjunctivitis is arguably the most common ocular adnexal infection, and it is often difficult to determine the etiology due to the vast number of causes of this condition. Bennett et al. reported a multiplex real-time PCR assay for B. R. Costin J. D. Perry (&) Cole Eye Institute, Cleveland Clinic, 9500 Euclid Avenue, Mail Code i-20, Cleveland, OH 44195, USA e-mail: perryj1@ccf.org

Uveal Lymphoma: Clinical Features, Diagnostic Studies, Treatment Selection, and Outcomes

To describe the clinical features, ancillary diagnostic studies, and treatment selection in a cohort of patients with uveal lymphoma. Retrospective clinical review. A total of 22 patients (34 affected eyes) diagnosed with uveal lymphoma between 1997 and2013. Data were collected regarding patient characteristics, clinical features on ophthalmic examination, ancillary imaging studies, and primary treatment selection. Relapse defined as lymphoma recurrence in the initial site of presentation, the contralateral eye, or other systemic site and overall survival. Fifteen patients were male (68.2%). Median age at diagnosis was 68.0 years. The choroid was involved in 21 cases (95.5%), and 1 case (4.5%) was ciliochoroidal. Other ocular adnexal structures were affected in 13 patients (59.1%), including the conjunctiva in 4 (18.2%), the orbit in 7 (31.8%), and both the conjunctiva and orbit in 2 (9.1%). Bilateral disease was present in 12 patients (54.5%). The most common presenting symptom was decreased vision in 15 patients (68.2%). The median delay in diagnosis was 4.0 months. Yellow-white choroidal infiltrates were observed on fundus examination in 34 eyes (100.0%) with corresponding hypofluorescence in 100% of cases when indocyanine green angiography was performed. Infiltrates were located anterior to the arcades (67.6%), most commonly in a diffuse (32.4%) or superotemporal (32.4%) distribution. B-scan ultrasonography detected extrascleral extension in 22 patients (75.9%) with a pattern of crescentic thickening in 19 (86.4%). Extranodal marginal zone lymphoma was the predominant (76.2%) histologic subtype. External beam radiotherapy (72.7%) was most commonly chosen for primary treatment. Systemic imaging at the time of diagnosis revealed that the majority of cases (77.3%) were localized to the eye; none of the patients developed new systemic disease (median follow-up, 30.3 months). Uveal lymphoma has distinctive clinical features. Overlap with ocular adnexal structures is common, and ancillary imaging is essential for evaluating the full extent of ocular disease and presence of systemic involvement.

Ocular Adnexal Lymphoma: Assessment of a Tumor-Node-Metastasis Staging System

To assess distribution, correlations, and prognostic effect of tumor (T), node (N), and metastasis (M) staging on relapse and survival. Retrospective clinical review. Sixty-three patients diagnosed with primary ocular adnexal lymphoma (OAL) between January 1986 and November 2011. Complete ocular examination and systemic evaluation were performed. Patients were staged according to the American Joint Committee on Cancer (AJCC) seventh edition tumor-node-metastasis (TNM) clinical staging system for OAL and followed every 6 to 12 months (median follow-up, 27.9 months). Relapse defined as lymphoma recurrence in the initial site of presentation, the contralateral ocular adnexal structures, or other systemic site and overall survival. There were 40 men (63.5%). The median age was 65 years (range, 24-85 years). The affected site was the conjunctiva in 27 patients (42.9%), orbit in 38 patients (60.3%), and eyelid in 3 patients (4.8%). The histologic subtype was extranodal marginal zone lymphoma (EMZL) in 51 patients (81.0%). A total of 14 patients (23.3%) had T1, 42 patients (70.0%) had T2, 1 patient (1.7%) had T3, and 3 patients (5.0%) had T4 disease. A total of 48 patients (82.8%) had N0 disease, and 10 patients (17.2%) had N1-4 disease. M stage was M0 in 47 patients (81.0%) and M1 in 11 patients (19.0%). With advanced T stage, there was an increase in both N1-4 (P = 0.045) and M1 disease (P = 0.041). M1 disease was greater among patients with N1-4 disease compared with N0 stage (50.0% vs. 12.5%, P = 0.003). Overall, 18 patients (28.6%) relapsed and 6 patients (9.5%) died. In Cox analysis, relapse was not associated with T stage (hazard ratio [HR], 1.14 per 1 level increase, P = 0.71), N stage (HR, 1.47; P = 0.51 N1-4 vs. N0), or M stage (HR, 1.22; P = 0.76 M1 vs. M0). T stage was not associated with survival (HR, 0.86; P = 0.81), whereas N1-4 had marginally worse survival than N0 (HR, 5.35; P = 0.07), and M1 had worse survival than M0 (HR, 9.27; P = 0.008). The TNM staging system for primary OAL is useful for precise characterization of extent of local disease. Although T stage does not predict relapse or survival, N1-4 and M1 stages indicated less favorable survival. The author(s) have no proprietary or commercial interest in any materials discussed in this article.

Unilateral Eyelid Mass as an Unusual Presentation of Ocular Adnexal IgG4-Related Inflammation

IgG4-related sclerosing disease is a new clinicopathologic systemic entity, which can involve ocular adnexal structures, such as lacrimal glands and orbital tissues. However, this entity seems to display a more diffuse, frequently bilateral, pattern in such cases. Conjunctival involvement has not been reported in this disease. We report the case of a 67-year-old woman with left upper palpebral mass for 5 months. A biopsy was performed, and the patient underwent systemic evaluation for IgG4-related disease. The clinicopathologic study revealed intense lymphoplasmacytic and sclerosing inflammation, with IgG4-positive plasma cells and an IgG4:IgG ratio >40%. The conjunctiva was also involved, which was different from previous studies. The only abnormality was hyperglycemia at 180 mg/dL (reference range, 70-99 mg/dL) and a raised glycosylated hemoglobin at 7.8%. Serum IgG and IgG4 levels were normal. Our case presented an unusual framework of ocular adnexal IgG4-related inflammation, with a more benign and restricted palpebral manifestation involving the conjunctiva.

Management of Ocular Conditions in the Burn Unit: Thermal and Chemical Burns and Stevens-Johnson Syndrome/Toxic Epidermal Necrolysis

Patients in burn intensive care units suffer from potentially life-threatening conditions including thermal or chemical burns and Stevens-Johnson syndrome/toxic epidermal necrolysis. There is often involvement of the ocular surface or adnexal structures which may be present at the time of hospital admission or may develop later in the hospital course. This article will describe the types of ocular burns, the mechanisms and manifestations of Stevens-Johnson syndrome/toxic epidermal necrolysis, the circumstances that may influence outcome, and acute and long-term treatment strategies, including new and evolving options.

Orbital Cellulitis: Medical and Surgical Management

Introduction: Orbital cellulitis is a potential sight-threatening infection of the ocular adnexal structures posterior to the orbital septum. Acute bacterial sinusitis remains the most common cause of orbital cellulitis.Methods: A retrospective chart review was performed for patients admitted to The Royal Victorian Eye and Ear Hospital with a diagnosis of orbital cellulitis over a five-year period to July 2009.Results: 78 patients were identified for inclusion in the study, median age 42 years. Sinusitis was the most common predisposing factor, and was present in 52 patients (67%). All patients were treated with intravenous antibiotics. Surgical drainage was required for 28 patients (36%). Of these patients, 3 underwent endoscopic drainage only, 21 underwent open drainage, and 4 patients underwent a combination of open and endoscopic drainage. The most significant complication seen was persistent decreased visual acuity despite treatment, which was present in 5 patients (6%).Discussion: Orbital cellulitis remains a potentially sight-threatening infection that requires careful management, preferably by combined ENT and Ophthalmology teams. Surgery is reserved for those patients in whom signs of visual compromise are present initially, or in those who fail to improve with maximal medical management. Currently endoscopic drainage is not the most common surgical approach, however for selected patients it appears a safe comparable alternative.

Congenital osteoma cutis of the lateral canthus

Osteoma cutis is a rare condition involving the formation of bone in skin or subcutaneous tissue. This may be a primary event or, more often, secondary to an inflammatory, traumatic, or neoplastic process. There is little evidence in the literature of this condition involving the eye or ocular adnexal structures. The authors report two remarkably similar cases involving children with congenital isolated osteoma cutis involving the left lateral canthus.

Neoadjuvant chemotherapy–specific and overall treatment outcomes in patients with cutaneous angiosarcoma of the face with periorbital involvement

Recent isolated case reports have suggested a potential role for neoadjuvant chemotherapy in patients with angiosarcoma. The goal of this report was to investigate the overall treatment outcomes and the neoadjuvant chemotherapy-specific outcomes in patients with cutaneous angiosarcoma of the face with periorbital involvement. Our tumor database was searched for patients with angiosarcoma and periorbital involvement seen at our institution between 1981 and 2005. Twenty-one patients were identified,15 of whom had neoadjuvant chemotherapy and 6 of whom had a traditional approach of surgery followed by adjuvant therapy. Fourteen of 15 patients who had neoadjuvant chemotherapy had complete clinical response. Neoadjuvant chemotherapy made definitive surgery unnecessary for 9 patients. The median disease-free interval for the neoadjuvant chemotherapy group was 11.8 months (mean, 38.1 months; range, 2.4-239.6 months). Nine of the 15 patients had recurrences. The time from end of treatment to recurrence ranged from 2.6 to 24.5 months (median, 12.7 months). Five of the 6 patients who had primary surgical resection followed by adjuvant radiotherapy and/or chemotherapy had a complete clinical response, and the median disease-free interval was 31.8 months (mean, 35.9 months; range, 2.7-85 months). Two later developed recurrences, one at 2.7 months and the other at 31.8 months after the end of treatment. On the basis of this series, the authors conclude that neoadjuvant chemotherapy for periorbital angiosarcoma is a potentially attractive option and in some patients may obviate the need for major surgery, thereby preserving the eye and/or ocular adnexal structures. Given the propensity for recurrence and poor survival, the authors strongly recommend that these patients receive multidisciplinary evaluation and treatment at a major cancer center.

Common conditions and practical considerations in eye care

As part of Nursing Standards clinical skills series, this article presents an overview of the structure and function of the eye, including ocular adnexal structures. This provides a basis for a forthcoming discussion of eye pathology and eye care.

Should Eye Structures Be Specified During IMRT Planning?

Purpose/Objective: One key process in IMRT planning is delineating sensitive structures and setting dose constraints for these structures. For patients with orbital and paranasal sinus tumors, many important optic structures approximate the tumor volume. The purpose of this study is to investigate whether eye structures should be specified with different dose constraints during IMRT planning, including the cornea, retina, and ocular adnexal structures such as the lacrimal gland. It has been reported that the rate of severe complications from lacrimal gland irradiation increases steeply above doses of 30 Gy, and reaches 5–41% by 40 Gy.

Parasites and the eye.

Systemic parasitic infections can result in intraocular inflammation. They are a major cause of blindness in many parts of the world. Infection usually results from bloodborne transmission of the organism to the eye or ocular adnexal structures. Diagnosis is often made from clinical patterns of disease in the eye, with laboratory investigations and imaging to support the diagnosis. Various local and systemic therapies are available, but may have limited success in preserving vision.

Ultrasound biomicroscopy of ocular adnexal structures

INTRODUCTION Ultrasound biomicroscopy (UBM) works on the principle of B-scan sonography. The spatial resolution is improved by using high-frequency transducers of 34–100 MHz. The study was performed to investigate UBM as a diagnostic tool for ocular adnexal disease.METHOD Lid and lacrimal structures of 10 normal individuals and 30 patients with pathological features were examined by UBM, using 50 and 34 MHz transducers. In cases of tumors the images were compared to the clinical features and histopathological findings of the excised lesions.RESULTS The tissue penetration is 2–3.5mm with the 50 MHz and up to 4.5 mm with the 34 MHz transducer. Normal subcutaneous structures of the lids and the lacrimal system can be visualized and identified. Using a video recording system improves the visibility and recognizability of the structures significantly. Histopathological diagnosis was not established by UBM in any of the excised lesions.CONCLUSIONS UBM can provide images of subcutaneous ocular adnexal structures and foreign bodies with good spatial resolution and acceptable tissue penetration. The instrument represents a non-invasive device for the visualization of normal upper lid and the lacrimal drainage system anatomy. Recognition of typical patterns in particular pathologic lesions might be possible. Histopathological diagnosis by UBM cannot be expected.

Transconjunctival Frontalis Suspension (TCFS)

We have devised a frontalis suspension technique originally described in an article entitled, "Transconjunctival frontalis suspension for blepharoptosis" (Trans Am Acad Ophthal Otolaryngol 83:684-92), by Swan and Tongue in 1977. This modified transconjunctival frontalis suspension (TCFS) procedure is described. It has been used at the Oregon Health Sciences University in its original or modified form since 1970. To better understand how this procedure successfully corrects blepharoptosis in patients with poor levator function, a study was undertaken to discern the anatomic relationship of the suspension material to important ocular adnexal structures. The findings are based on gross anatomic dissection and histologic examination of a cadaver eyelid after postmortem transconjunctival fascia lata frontalis suspension. The distal, horizontal limb of the fascia suspends the central portion of the levator aponeurosis in a hammock-type fashion. The two vertical limbs pierce the aponeurosis at the level of Whitnall's ligament and incorporate this ligament. The fascia then exits the orbit through the orbital septum near the arcus marginalis and is incorporated into the frontalis muscle near the junction of the medial one-third and lateral two-thirds of the brow, temporal to the supraorbital neurovascular bundle. This anatomic location is not only relatively easily and safely attained, but also maximizes the principles of more traditional frontalis suspensions while minimizing the effort and surgical manipulation.

Granular Cell Tumor (Myoblastoma) of the Palpebral Conjunctiva Causing Pseudoepitheliomatous Hyperplasia of the Conjunctival Epithelium

Granular cell tumors rarely occur in the ocular adnexal structures and only three cases have been described in which the eyelid alone was involved. I examined a patient who was, I believe, the first in whom a granular cell tumor appeared clinically as a conjunctival lesion. She was also the first patient with a granular cell tumor of the ocular adnexa to exhibit pseudoepitheliomatous hyperplasia of the overlaying epithelium, a pathologic feature associated with granular cell tumors originating elsewhere in the body.

Combined surgical approach in a late case of orbital cellulitis

Orbital cellulitis refers to infection of the ocular adnexal structures posterior to the orbital septum. The infection most commonly originates from the sinuses. Mucopyoceles are infected cysts of mucous content that affect the paranasal sinuses most commonly the frontal sinus. Many of these lesions have an intraorbital extension causing vision-threatening ocular complications such as orbital cellulitis and intracranial extension causing life-threatening neurological complication like meningitis. We treated a 12-year-old female patient of acute orbital cellulitis secondary to frontoethmoidal mucopyocele with combined surgical approach - transnasal endoscopic and open surgical drainage.