We present an unusual case of a patient who acquired a pansinusitis and orbital cellulitis with necrotizing features, subsequently developing scleritis, keratitis, and anterior uveitis. To date, there are no reported cases of the
The accumulated dogma and literature in oculopastic surgery suggest that a blood supply is needed to 1 of the 2 lamellae for a full thickness eyelid graft to survive. Texts such as that of the American Academy of Ophthalmology monograph note that, "To prevent necrosis, at least one of the flaps must bring a vascular supply with it to support the other flap. In other words, only one of the lamellae can be reconstructed as a free graft; the other has to be a local flap tethered at its base to the vascular supply." 2 This admonishment is repeated in many other oculoplastics texts on our bookshelf. 3,4 Key principles for skin grafts at any location include that during the first 48 hours after a graft is placed, the plasma exudate from host bed capillaries nourishes the graft; revascularization commences at 48 hours with neovascularization from the recipient bed in the graft, followed by inosculation in which graft and host vessels form anastomoses. 5 The authors have proven otherwise in their select cohort of 10 patients. The 1 patient who dehisced the graft at 3 days had a reportedly viable graft.The idea of a free composite or bilamellar eyelid graft has been contemplated for many years as it holds advantages over the modified Hughes flap in being a 1-stage procedure that does not occlude the vision. Reports of successful free grafts have been in the literature for years, including from some of the founding members of American Society for Ophthalmic Plastic and Reconstructive Surgery. [6][7][8] However, the high failure rates of these this type of graft led to its falling out of favor and modification of techniques to provide a pedicled blood supply. 9 The patients in the author's cohort are described as otherwise healthy. Many patients who require skin grafting, particularly for reconstruction following excision of skin cancer, are not ideal graft candidates with compromised blood supply from either years of smoking, cardiovascular disease, diabetes, obesity, and poor diet. The principles of blood supply may need to be respected in these patients.The innovative work of the authors is noteworthy but prompts us to remember the failures reported in the past and the central tenants of skin grafting to the eyelids.
A 22-year-old woman presented with an acute compressive optic neuropathy due to a ruptured ethmoido-orbital mucocele. She underwent urgent orbital decompression and drainage of the mucocele via an endoscopic approach. Postoperatively, her course was complicated by an orbital compartment syndrome supervened, exhibiting severe eyelid edema caused by infiltration with mucin and mucin-containing macrophages (“muciphages”). Biopsy of the eyelid showed infiltration with “muciphages,” macrophages laden with extravasated mucinous material. This is the first report that documents the clinical and histopathologic course of orbital inflammation following mucocele extravasation into the orbit and eyelids.
FIG. 2.Histology of left upper eyelid biopsy and excision. On lower power (A), there are nodules of neoplastic cells (circles) associated with a desmoplastic reaction (arrow). On higher magnification (B), scant blue mucus cells (circle) with epithelial cells and lymphocyte infiltrate can be visualized. Mucicarmine staining (C) was done which demonstrated small islands of mucus (circle). There was no residual tumor seen at the margins of the excision specimen (D) but there was a dense lymphocytic infiltrate (arrow).
These findings have direct implications for the assessment of athlete performance on vision-based and other verbal sideline concussion tests; these results are particularly important given the international scope of sport. Pre-season baseline scores are essential to evaluation in the event of concussion, and performance of sideline tests in the athlete's native language should be considered to optimize both baseline and post-injury test accuracy.
A 74-year-old man presenting with proptosis and orbital inflammation was found on magnetic resonance imaging to have a unilateral intraconal mass. Biopsy revealed a high-grade malignant tumor that was interpreted as squamous cell carcinoma. Positron emission tomography-computed tomography imaging subsequently identified a primary lesion in the esophagus. Esophageal squamous cell carcinoma is a rare cause of orbital metastasis, with only 4 previously reported cases. The authors discuss an approach to orbital malignancies of obscure origin.
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