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Vongsachang H, Chiou CA, Azad AD, Lin LY, Yoon MK, Lefebvre DR, Stagner AM. Periorbital necrotizing sweet syndrome: A report of two cases mimicking necrotizing soft tissue infections. Am J Ophthalmol Case Rep 2024; 34:102033. [PMID: 38487334 PMCID: PMC10937104 DOI: 10.1016/j.ajoc.2024.102033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Revised: 02/08/2024] [Accepted: 02/20/2024] [Indexed: 03/17/2024] Open
Abstract
Purpose Two cases are described of necrotizing Sweet syndrome (nSS), a rare variant of acute febrile neutrophilic dermatosis that mimics necrotizing soft tissue infections. Observation A 74-year-old female with myelodysplastic syndrome (MDS) presented with isolated periorbital nSS that closely mimicked necrotizing fasciitis (NF); she displayed pathergy to debridement, was exquisitely responsive to corticosteroids, and underwent successful first-stage reconstruction of the eyelid with full-thickness skin grafting. A second 40-year-old female patient with relapsed acute myelogenous leukemia (AML) presented with multifocal nSS most prominently involving the eyelid. Positive herpes zoster virus (HSV) PCR and bacterial superinfection complicated the diagnosis. She improved with chemotherapy for AML and corticosteroid therapy. Conclusion nSS is rare and a high level of clinical suspicion as well as an understanding of its distinguishing features is necessary to avoid undue morbidity. Identification of pathergy, histopathology, microbiology, and clinical context are critical to avoid misdiagnosis of infection.
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Affiliation(s)
- Hursuong Vongsachang
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Carolina A. Chiou
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Amee D. Azad
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Lisa Y. Lin
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Michael K. Yoon
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Daniel R. Lefebvre
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
| | - Anna M. Stagner
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear, Harvard Medical School, Boston, MA, USA
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2
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Lu JE, Wolkow N, Lee NG, Lefebvre DR, Freitag SK, Yoon MK. Perceived change in age after functional upper blepharoplasty. Orbit 2024; 43:165-167. [PMID: 37224403 DOI: 10.1080/01676830.2023.2214940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 05/10/2023] [Indexed: 05/26/2023]
Abstract
PURPOSE To evaluate the perceived age of patients before and after functional upper blepharoplasty. METHODS Retrospective chart review of patients who underwent upper blepharoplasty by a single surgeon at an academic center. The inclusion criterion was having external photographs before and after blepharoplasty. Exclusion criteria included any other concurrent eyelid or facial surgery. Primary endpoint: perceived change in age after surgery as judged by the American Society of Ophthalmic Plastic & Reconstructive Surgery (ASOPRS) surgeons. RESULTS Sixty-seven patients (14 men, 53 women) were included. Mean pre-operative age was 66.9 years (range 37.8-89.4) and mean post-operative age was 67.4 years (range 38.6-89). The mean perceived age pre-operatively was 68.9 years, and the mean perceived age post-operatively was 67.1 years, a change of 1.8 years (p = 0.0001 by two-tailed paired T-test). Inter-rater reliability of the observers was measured by intraclass correlation coefficient of 0.77 for pre-operative and 0.75 for post-operative photos. The decreased perceived age was 1.9 years for women, 1.4 years for men, 0.3 years for Asians, 1.2 years for Hispanics, and 2.1 years for whites. DISCUSSION Functional upper blepharoplasty by an experienced ASOPRS surgeon was shown to reduce the perceived age of a patient by an average of 1.8 years.
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Affiliation(s)
- Jonathan E Lu
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Natalie Wolkow
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - N Grace Lee
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Daniel R Lefebvre
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
| | - Michael K Yoon
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, USA
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3
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Lin LY, Lefebvre DR. Orbital Penetrating Injuries: A Review on Evaluation and Management. Int Ophthalmol Clin 2024; 64:11-29. [PMID: 38525979 DOI: 10.1097/iio.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/26/2024]
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4
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Boal NS, Chiou CA, Sadlak N, Sarmiento VA, Lefebvre DR, Distefano AG. Antibiotic utilization in endoscopic dacryocystorhinostomy: a multi-institutional study and review of the literature. Orbit 2024; 43:183-189. [PMID: 37395439 DOI: 10.1080/01676830.2023.2227705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2023] [Accepted: 06/15/2023] [Indexed: 07/04/2023]
Abstract
PURPOSE Utilization of antibiotics for endoscopic dacryocystorhinostomy (endo-DCR) is largely dependent on individual surgeon preference. This study aimed to investigate prescribing practices of pre-, peri-, and postoperative antibiotics and effects on postoperative infection rates in patients who underwent endo-DCR. METHODS A retrospective chart review of institutional data at two academic centers of endo-DCR cases from 2015-2020 was performed. Postoperative infection rates for patients who received pre-, peri-, and postoperative antibiotics, individually or in combination, and those who did not, were compared via odds ratio and ANOVA linear regression. RESULTS 331 endo-DCR cases were included; 22 cases (6.6%) had a postoperative infection. There was no significant difference in the infection rates between patients without an active preoperative dacryocystitis who received different permutations of peri- and postoperative antibiotics. Patients who received preoperative antibiotics within two weeks of surgery for preexisting acute dacryocystitis, but did not receive peri- or postoperative antibiotics, had a higher rate of postoperative infections (p = 008). CONCLUSIONS Our data suggest antibiotics may be beneficial only when patients have a recent or active dacryocystitis prior to surgery. Otherwise, our data do not support the routine use of antibiotic prophylaxis in endo-DCR.
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Affiliation(s)
- Nina S Boal
- Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Carolina A Chiou
- Division of Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalie Sadlak
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - V Adrian Sarmiento
- Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Daniel R Lefebvre
- Division of Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
- Division of Ophthalmology, Surgical Service, Boston Veterans Affairs HealthCare System, Boston, Massachusetts, USA
- Dedham Ophthalmic Consultants and Surgeons / Lexington Eye Associates, Dedham, Massachusetts, USA
| | - Alberto G Distefano
- Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
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Chang EK, Chiou CA, Lefebvre DR, Stagner AM. A Rapidly Expanding Hemorrhagic BRAF-Mutant Orbital Atypical Glomus Tumor. Ophthalmic Plast Reconstr Surg 2024; 40:e11-e14. [PMID: 37695168 DOI: 10.1097/iop.0000000000002513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
A healthy 32-year-old woman presented with the acute onset of left sided eye pain, upper eyelid fullness, and binocular diplopia during light weightlifting. Examination elevated intraocular pressure, proptosis, upper eyelid ptosis, and motility deficits. CT demonstrated a well-circumscribed, homogeneous-appearing extraconal mass in the superior left orbit. The patient underwent an urgent orbitotomy with the excision of a hemorrhagic mass. Histopathology showed a glomus tumor with atypical features and hemorrhagic infarction, best classified as having uncertain malignant potential. A B-Raf proto-oncogene V600E mutation was detected with immunohistochemistry, which suggests a more aggressive tumor behavior yet presents an opportunity for targeted primary or adjunctive therapy. This is the first reported case of a B-Raf proto-oncogene-mutant atypical glomus tumor arising in the orbit.
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Affiliation(s)
- Enchi K Chang
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
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6
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Liebman DL, Tam EK, Lithgow MY, Kane JE, Fischbein NJ, Lefebvre DR, Chwalisz BK, Gaier ED. Optic Perineuritis Associated With Cryptococcal Meningitis Presenting With a "Hot Orbit" in a Patient With Chronic Lymphocytic Leukemia. J Neuroophthalmol 2022; 42:272-277. [PMID: 35421041 PMCID: PMC9124683 DOI: 10.1097/wno.0000000000001538] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT A 75-year-old man presented with 3 days of progressive left retro-orbital pain, eyelid swelling, tearing, and pain with extraocular movement. His medical history was significant for type II diabetes mellitus and chronic lymphocytic leukemia, stable on no therapy since diagnosis 8 years prior. The initial examination was significant for diffuse restriction of left ocular motility, marked lid edema, and mild dyschromatopsia. Computed tomography demonstrated asymmetric left periorbital soft tissue swelling and intraconal fat stranding with an irregular left optic nerve sheath complex and clear paranasal sinuses. He was hospitalized for orbital cellulitis and treated empirically with broad-spectrum intravenous antibiotics, but his visual acuity declined over the ensuing 2 days. Subsequent MRI demonstrated left-greater-than-right circumferential optic nerve sheath enhancement, and leptomeningeal enhancement. An orbital biopsy demonstrated monoclonal B-cell lymphocyte aggregation, whereas a lumbar puncture was positive for Cryptococcus antigen with subsequent demonstration of abundant Cryptococcus by Papanicolaou stain. The final diagnosis was optic perineuritis secondary to cryptococcal meningitis presenting with orbital inflammation. Although his clinical course was complicated by immune reconstitution inflammatory syndrome, symptoms and signs of optic neuropathy ultimately resolved after 1 month of intensive antifungal therapy.
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MESH Headings
- Aged
- Diabetes Mellitus, Type 2/complications
- Edema
- Humans
- Leukemia, Lymphocytic, Chronic, B-Cell/complications
- Leukemia, Lymphocytic, Chronic, B-Cell/diagnosis
- Male
- Meningitis, Cryptococcal/complications
- Meningitis, Cryptococcal/diagnosis
- Meningitis, Cryptococcal/drug therapy
- Orbit
- Pain/complications
- Vision Disorders
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Affiliation(s)
| | - Emily K. Tam
- Department of Ophthalmology, Boston Medical Center, Boston, MA
| | | | - Joseph E. Kane
- Department of Optometry, Boston VA Medical Center, Boston, MA
| | - Nancy J. Fischbein
- Department of Radiology, Stanford University Medical Center, Stanford, CA
| | - Daniel R. Lefebvre
- Department of Ophthalmology, Boston VA Medical Center, Boston, MA
- Division of Ophthalmic Plastic and Reconstructive Surgery, Mass Eye and Ear, Boston, MA
| | - Bart K. Chwalisz
- Division of Neuro-Ophthalmology, Mass Eye and Ear, Boston, MA
- Division of Neuro-Immunology, Massachusetts General Hospital, Boston, MA
| | - Eric D. Gaier
- Department of Ophthalmology, Mass Eye and Ear, Boston, MA
- Department of Ophthalmology, Boston Children’s Hospital, Harvard Medical School, Boston, MA
- Picower Institute for Learning and Memory, Massachusetts Institute of Technology, Cambridge, MA
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7
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Habib LA, North VS, Freitag SK, Yoon MK, Lefebvre DR, Grace Lee N. Medical comorbidities and orbital implant exposure. Acta Ophthalmol 2022; 100:e813-e819. [PMID: 34233090 DOI: 10.1111/aos.14973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 06/17/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE To investigate medical conditions and systemic therapies associated with orbital implant exposure in patients with anophthalmic sockets. METHODS Retrospective review of patients who underwent enucleation or evisceration at a single centre between January 1, 2008 and March 1, 2018. Medical comorbidities, including peripheral or coronary artery disease, rheumatologic conditions, diabetes, malignancy and history of smoking were recorded. Use of immunomodulatory and anticoagulation therapy at the time of eye removal was noted. Patients were divided into two groups-those with implant exposure and those without. Univariate and multivariate analysis was used to compare groups. RESULTS Two hundred and twenty-nine patients underwent eye removal surgery over a ten-year period. Implant exposure was seen in 20 (8.7%) patients. Univariate analysis revealed a statistically significant difference between groups in rates of smoking, malignancy, and immunomodulatory therapy at the time of surgery. A history of smoking (HR = 11.72; 95% CI: 2.95, 46.53; p = 0.0001) and immunomodulatory therapy (HR = 8.02; 95% CI: 1.96, 32.87; p = 0.004) were independent predictors of exposure. The probability of exposure was 81.2% when all three risk factors were present versus 4.4% when none were present (c-index = 0.737, 95% CI: 0.608, 0.865; p < 0.001). The model was a good fit to the data (Hosmer-Lemeshow goodness-of-fit test p = 0.475). CONCLUSIONS Smoking and immunomodulatory therapy were associated with orbital implant exposure in patients with anophthalmic sockets. This is the first report examining medical comorbidities in patients with orbital implant exposure. Understanding the pathophysiology of implant exposure is crucial to preoperative planning and postoperative care.
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Affiliation(s)
- Larissa A. Habib
- Oculoplastic and Reconstructive Surgery Division Department of Ophthalmology Yale Medical School New Haven CT USA
| | - Victoria S. North
- Oculoplastic and Orbital Surgery Edward S. Harkness Eye Institute Columbia University Irving Medical Center New York‐Presbyterian Hospital New York NY USA
| | - Suzanne K. Freitag
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
| | - Michael K. Yoon
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
| | - Daniel R. Lefebvre
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
| | - Nahyoung Grace Lee
- Department of Ophthalmology Harvard Medical School Boston MA USA
- Ophthalmic Plastic Surgery Service Massachusetts Eye and Ear Boston MA USA
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8
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Tam EK, Laver NV, Thakore-James M, Mooney MA, Daly MK, Lefebvre DR. ARHGEF-10 gene mutation presenting as orbital inflammatory syndrome. BMJ Case Rep 2022; 15:e245475. [PMID: 35260397 PMCID: PMC8905991 DOI: 10.1136/bcr-2021-245475] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/03/2022] Open
Abstract
Rho guanine nucleotide exchange factor 10 (ARHGEF-10) is a RHO GTPase that has a role for neural morphogenesis, however its effect on the eyes remains unknown. Here, we report a 44-year-old man who presented with eyelid swelling along with a history of bilateral hand contractures, high-arched feet and muscle wasting, who was found to have an ARHGEF-10 mutation. Neuroimaging was significant for numerous nerve-based cystic abnormalities in the bilateral orbits and throughout the neuraxis, and an orbital biopsy revealed S-100 and SOX-10 positive lesion consistent with pseudocysts. While the role of ARHGEF-10 remains unclear, further research is warranted to further describe its clinical manifestations.
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Affiliation(s)
- Emily K Tam
- Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston, MA, USA
| | - Nora V Laver
- Department of Pathology and Department of Ophthalmology, Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Manisha Thakore-James
- Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA
- Department of Neurology, Harvard Medical School, Boston, MA, USA
| | - Michael A Mooney
- Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
- Department of Neurosurgery, Harvard Medical School, Boston, MA, USA
| | - Mary K Daly
- Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA
- Department of Ophthalmology, Boston University School of Medicine, Boston, MA, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
| | - Daniel R Lefebvre
- Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts, USA
- Department of Ophthalmology, Harvard Medical School, Boston, MA, USA
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9
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Hanbazazh M, Jakobiec FA, Curtin HD, Lefebvre DR. Orbital Involvement by Biphenotypic Sinonasal Sarcoma With a Literature Review. Ophthalmic Plast Reconstr Surg 2021; 37:305-311. [PMID: 32991500 DOI: 10.1097/iop.0000000000001839] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE To document a case of a biphenotypic sinonasal sarcoma that impinged on the orbit via a tumor-induced mucocele and review the previous literature devoted to this condition. METHODS A clinicopathologic case report with detailed histopathologic, immunohistochemical, and radiological studies with tabulations of previously reported cases and immunohistochemical stains for ruling out mimicking lesions. RESULTS A biphenotypic sinonasal sarcoma arose from the ethmoid sinus in a middle-aged man. The tumor induced a mucocele that bowed the medial orbital lamina papyracea into the orbit and caused diplopia and mild proptosis. The biopsy's dual positivity for S100 and smooth muscle actin together with positive paired box 3 immunohistochemical staining established the diagnosis of biphenotypic sinonasal sarcoma. CONCLUSION Biphenotypic sinonasal sarcoma, which can involve the orbit in 25% of cases, is a rare head and neck malignancy that has only recently been described. Biphenotypic sinonasal sarcoma is a low-grade, locally aggressive, nonmetastasizing sarcoma displaying both neural and muscle differentiation. It is further characterized by rearrangements of the PAX3 gene with multiple fusion partners, most commonly MAML3 (Mastermind like transcriptional coactivator 3). It occurs predominantly in middle-aged women and exclusively in the sinonasal tract. However, it can spread throughout the central facial structures to invade the brain if not detected early. Ophthalmologists should be aware of this new entity to avoid delays in diagnosis and treatment. The previous literature devoted to this condition was reviewed and analyzed for clinical, radiological, histopathological, and immunohistochemical features. In circumstances where molecular testing is not available, paired box 3 immunohistochemical staining can be used as an alternative diagnostic marker. The current case is most unusual because the orbital findings were induced by a mucocele caused by the tumor that obstructed the sinus ostium. This produced diplopia without direct tumor invasion into the orbital fat.
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Affiliation(s)
- Mehenaz Hanbazazh
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear
- Department of Ophthalmology, Harvard Medical School
| | - Frederick A Jakobiec
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear
- Department of Ophthalmology, Harvard Medical School
| | | | - Daniel R Lefebvre
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
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10
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Boal NS, Cretara EAZ, Bleier BS, Lam AC, Lefebvre DR. In vivo analysis of endocanalicular light pipe transillumination in endoscopic dacryocystorhinostomy: Anatomic considerations and cautions for the transitioning. Orbit 2021; 41:447-451. [PMID: 34082644 DOI: 10.1080/01676830.2021.1929340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Purpose: Localization of the lacrimal sac is a critical step during endoscopic dacryocystorhinostomy (endo-DCR). A "light pipe" can be used to transilluminate the lacrimal sac endonasally. We hypothesized that this may misguide the surgeon learning endo-DCR to create an osteotomy mostly posterior to the maxillary line if only the bone overlying the transillumination was to be removed, as the thinner lacrimal bone will transmit light more readily than the thicker maxillary bone of the frontal process of the maxilla that forms the anterior lacrimal sac fossa.Methods: The charts of 32 patients with primary acquired nasolacrimal duct obstruction in whom a lighted system was used during endo-DCR at Massachusetts Eye and Ear from April 2015 through October 2016 were reviewed. Patients with prior history of lacrimal surgery or trauma directly to the lacrimal sac fossa were excluded. Location of the maximal point of transillumination in relation to the maxillary line was observed and noted intraoperatively.Results: Of a total of 39 endo-DCR surgeries performed, the intraoperative transillumination point was entirely posterior to the maxillary line in 32 instances (82%).Conclusions: Use of an endocanalicular light pipe preferentially illuminates posterior to the maxillary line endonasally. The anterior lacrimal sac fossa (maxillary line and anterior as visualized endonasally) is rarely transilluminated, likely due to thicker bone in that region. Surgeons learning how to perform endo-DCR using a light pipe should be aware of this phenomenon.
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Affiliation(s)
- Nina S Boal
- Department of Ophthalmology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Elizabeth A Z Cretara
- Casey Eye Institute and Department of Ophthalmology, Oregon Health and Science University, Portland, Oregon, USA
| | - Benjamin S Bleier
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Rhinology, Massachusetts Eye and Ear, Boston, Massachusetts, USA
| | - Allen C Lam
- Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Lefebvre
- Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA.,Division of Ophthalmic Plastic Surgery, Massachusetts Eye and Ear, Boston, Massachusetts, USA.,Division of Ophthalmology - Surgical Service, Boston Veterans Affairs HealthCare System, Boston, Massachusetts, USA
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11
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Green MB, Daly MK, Laver NMV, Lefebvre DR. Adult-onset asthma and periocular xanthogranuloma - A rare infiltrative disease of the orbit and eyelid. Am J Ophthalmol Case Rep 2021; 22:101043. [PMID: 33869889 PMCID: PMC8044650 DOI: 10.1016/j.ajoc.2021.101043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2020] [Revised: 01/25/2021] [Accepted: 02/22/2021] [Indexed: 11/06/2022] Open
Abstract
Purpose To present a case of adult onset asthma with periocular xanthogranuloma (AAPOX), and discuss existing literature on adult orbital xanthogranulomatous diseases (AOXGDs) and their treatment. Observations A 63 year old male presented with progressive bilateral eyelid swelling with overlying yellow plaques associated with asthma. CT scan showed periorbital swelling with enlargement of the superior and lateral rectus muscles bilaterally. Biopsy demonstrated orbital xanthogranulomatous disease with increased IgG4 plasma cells. The patient was treated with intralesional triamcinolone, oral prednisone, and cyclophosphamide without significant improvement. Surgical debulking was eventually performed which improved his external symptoms until he was lost to follow up 15 months later. Conclusions and Importance AOXGDs are a group of rare infiltrative diseases of the eyelids and orbit that can be associated with significant systemic morbidities. While they all have similar underlying histopathologic features, appreciating the clinical difference between these diseases is important in understanding patient prognosis and ensuring appropriate clinical monitoring. There is also growing research demonstrating that AAPOX, along with other AOXGDs, may represent part of a continuum of IgG4 related disease, similar to what is seen in this case. There is currently no reliably effective treatment for AOXGDs, and additional research into the management of these diseases is necessary.
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Affiliation(s)
- Michael B Green
- Veterans Affairs Boston Healthcare System, Department of Ophthalmology, 150 South Huntington Avenue, Boston, MA, 02130, USA.,Boston University School of Medicine, Department of Ophthalmology, 72 East Concord Street, Boston, MA, 02118, USA
| | - Mary K Daly
- Veterans Affairs Boston Healthcare System, Department of Ophthalmology, 150 South Huntington Avenue, Boston, MA, 02130, USA.,Boston University School of Medicine, Department of Ophthalmology, 72 East Concord Street, Boston, MA, 02118, USA.,Harvard Medical School, Department of Ophthalmology, 243 Charles Street, Boston, MA, 02114, USA
| | - Nora M V Laver
- Tufts University School of Medicine, Department of Ophthalmology and Department of Pathology and Laboratory Medicine, 800 Washington Street, Boston, MA, 02111, USA
| | - Daniel R Lefebvre
- Veterans Affairs Boston Healthcare System, Department of Ophthalmology, 150 South Huntington Avenue, Boston, MA, 02130, USA.,Harvard Medical School, Department of Ophthalmology, 243 Charles Street, Boston, MA, 02114, USA
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12
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Abstract
Purpose: To compare the incidence of lower eyelid malposition following repair of isolated orbital floor fractures with that of complex orbitofacial fractures (defined as multi-wall fractures or prior orbital fracture repairs requiring revision) by oculofacial plastic surgeons via a transconjunctival or swinging eyelid approach.Methods: Retrospective review of 175 patients who underwent surgical repair of orbital fractures at our institution. The primary outcomes were the occurrence of lower eyelid malposition (ectropion, entropion, and eyelid retraction) and the need for subsequent surgical correction.Results: Of 95 patients with isolated orbital floor fractures, 4 developed eyelid malposition (4.2%), 1 of which required surgical repair (1.1%). Of 80 patients with complex orbitofacial fractures (48 multi-wall fractures, 32 secondary revisions), 10 had pre-operative eyelid malposition and were excluded from further analysis. Fourteen of the remaining 70 patients developed postoperative eyelid malposition (20%), 3 of which required surgical repair (4.3%). The difference in the occurrence of eyelid malposition between groups was statistically significant (p = .001), but the difference in rates of those requiring subsequent repair was not (p = .182). There was no statistically significant difference in the occurrence of eyelid malposition when considering other surgical factors including lateral canthotomy, conjunctival closure, implant material, or anterior rim screws.Conclusions: The incidence of lower eyelid malposition following orbital fracture repair via a fornix-based approach was significantly higher for the repair of complex orbitofacial fractures than for isolated floor fractures. However, very few patients in either group required surgical repair for eyelid malposition. Surgical factors including implant material did not affect outcomes.
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Affiliation(s)
- Victoria S North
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Edith R Reshef
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Nahyoung Grace Lee
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Daniel R Lefebvre
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
| | - Michael K Yoon
- Ophthalmic Plastic Surgery Service, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA, USA
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13
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Jakobiec FA, Reshef ER, Ma L, Selig MK, Lefebvre DR, Stagner AM. Sclerosing Signet Ring Cell Carcinoma of the Lacrimal Gland: A Potentially New Primary Entity. Ocul Oncol Pathol 2020; 6:265-274. [PMID: 33005616 DOI: 10.1159/000505490] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 12/14/2019] [Indexed: 11/19/2022] Open
Abstract
An 88-year-old man presented with diplopia, limitation of extraocular movements, and a firm palpable mass in the superolateral orbit. Biopsy revealed a sclerosing signet ring cell carcinoma with histopathologic features mimicking those of a primary signet ring cell (histiocytoid) carcinoma of the eyelid of eccrine or apocrine gland origin, a metastasis from an invasive lobular breast carcinoma or a metastatic diffuse-type gastric carcinoma. An extensive panel of immunohistochemical stains and molecular genetic analyses unequivocally failed to establish a precise diagnosis. Electron microscopy demonstrated features of a primary lacrimal gland lesion with intracytoplasmic lumens and zymogen granules typical of lacrimal secretory pyramidal cells. A thorough initial systemic work-up failed to reveal a primary visceral malignancy. Fifteen months of follow-up have failed to detect the emergence of another primary malignancy. To the best of our knowledge, a tumor with the morphology of the current lesion has not been previously described in the major or accessory lacrimal glands.
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Affiliation(s)
- Frederick A Jakobiec
- David G. Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Edith R Reshef
- David G. Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Lina Ma
- David G. Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Martin K Selig
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Lefebvre
- Division of Ophthalmic Plastic Surgery, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA
| | - Anna M Stagner
- David G. Cogan Laboratory of Ophthalmic Pathology, Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, USA.,Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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14
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Abstract
PURPOSE Orbital trauma, particularly with open globe injury, can have a wide range of visual outcomes, which can be difficult to predict at presentation. Clinical features on presentation may provide insight into visual prognosis. We hypothesized that patients with open globe injuries and concomitant orbital fractures have poorer visual outcomes than patients without orbital fractures. METHODS We reviewed the charts of 77 patients with isolated open globe injuries (OG) and 76 patients with open globe injuries and concomitant orbital fractures (OGOF). Multivariate regression analysis was performed to assess the relative influence of individual presenting historical and clinical features on visual outcome. RESULTS OGOF patients were more likely to have sustained blunt trauma than a sharp, penetrating injury compared to OG patients. Ocular wound locations were more posterior and likely to involve multiple zones in OGOF compared to OG patients. Among OGOF patients, orbital floor fractures were the most common and roof fractures were the least common, but the latter was associated with presenting NLP vision and multiple zone involvement. The presence of an orbital fracture independently increased the odds of subsequent evisceration/enucleation (OR: 4.6, 95% CI 1.3-20.1, p = .0246) and NLP vision (OR: 6.81, 95% CI 2.42-21.85, p = .0005) when controlling for zone, mechanism of injury, uveal prolapse and demographic variables. CONCLUSIONS The presence of an orbital fracture independently confers a worse visual and ocular prognosis in patients with open globe injuries. Patients with open globe injuries in this category should be appropriately counseled.
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Affiliation(s)
- Eric D Gaier
- Department of Ophthalmology, Boston Children's Hospital , Boston, MA, USA.,Picower Institute for Learning and Memory, Department of Brain and Cognitive Sciences, Massachusetts Institute of Technology , Cambridge, MA, USA.,Department of Surgery, Medical University of South Carolina , Charleston, SC, USA.,Foundation Medicine , Cambridge, MA, USA
| | - Sami Tarabishy
- Department of Surgery, Medical University of South Carolina , Charleston, SC, USA
| | | | - Natalie Wolkow
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Boston, MA, USA.,Harvard Medical School , Boston, MA, USA
| | - Matthew Gardiner
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Boston, MA, USA.,Harvard Medical School , Boston, MA, USA
| | - Daniel R Lefebvre
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Boston, MA, USA.,Harvard Medical School , Boston, MA, USA
| | - Seanna Grob
- Department of Ophthalmology, University of California , San Francisco, CA, USA
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15
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Jakobiec FA, Cortes Barrantes P, Lefebvre DR, Milman T. Intraductal sebaceous papilloma of a meibomian gland: a new entity possibly associated with the MSH6 subtype of the Muir-Torre syndrome. Surv Ophthalmol 2019; 65:227-238. [PMID: 31557488 DOI: 10.1016/j.survophthal.2019.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2019] [Revised: 09/01/2019] [Accepted: 09/09/2019] [Indexed: 11/26/2022]
Abstract
Over several months, a painless, multinodular, non-erythematous swelling of the deep tissues of his left upper eyelid developed in a 63-year-old man. An excisional biopsy with histopathologic evaluation disclosed a unique sebaceous papilloma within a cyst lined by non-keratinizing squamous epithelium that focally displayed a variably thick, superficial, eosinophilic cuticular layer. Immunohistochemical staining demonstrated that the tumor and its epithelial cystic lining had a profile consistent with Meibomian gland duct epithelium. Adipophilin highlighted cytoplasmic vacuolar lipid positivity. The encapsulation of the lesion, absence of nuclear atypia, and Ki-67 nuclear positivity restricted to the basilar cells established its intrinsically benign nature. The patient's clinical history was remarkable for pulmonary and colonic carcinomas resected, respectively, 20 years and 8 years earlier. DNA mismatch repair protein expression studies disclosed loss of nuclear immunostaining of MSH6 protein, pointing to the possibility of an underlying rare MSH6 variant of the Muir-Torre syndrome, not yet described in the ophthalmic literature. p16 nuclear positivity was also found in the tumor cells, indicating the possible role of high-risk human papillomavirus as an additional factor in the genesis of the tumor. Genetic evaluation of normal and tumoral tissues in future similar cases will detect if there is an underlying germline mutation versus a somatic mutation limited to the tumor. This will be required to fully establish a predictable linkage with this new subtype of the Muir-Torre syndrome.
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Affiliation(s)
- Frederick A Jakobiec
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear/Harvard Medical School, Boston, Massachusetts, USA.
| | - Paula Cortes Barrantes
- David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear/Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Lefebvre
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear/Harvard Medical School, Boston, Massachusetts, USA
| | - Tatyana Milman
- Department of Ophthalmic Pathology, Wills Eye Hospital, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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16
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Affiliation(s)
- Daniel R Lefebvre
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - Katherine L Reinshagen
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - Michael K Yoon
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - John H Stone
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
| | - Anna M Stagner
- From the Departments of Ophthalmology (D.R.L., M.K.Y.) and Radiology (K.L.R.), Massachusetts Eye and Ear, the Departments of Medicine (J.H.S.) and Pathology (A.M.S.), Massachusetts General Hospital, and the Departments of Ophthalmology (D.R.L., M.K.Y.), Radiology (K.L.R.), Medicine (J.H.S.), and Pathology (A.M.S.), Harvard Medical School - all in Boston
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17
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Abstract
A 53-year-old male presented with a bony lesion over the superior orbital rim increasing in size over several months. CT imaging showed a circumscribed, osseous lesion involving the outer table of the right frontal bone and superior orbital rim with a honeycomb appearance. Anterior orbitotomy revealed an osseous lesion along the superior orbital rim with purple cavernous spaces. Histopathological examination demonstrated cavernous vascular channels with variably-sized lumens and variably-thickened vascular walls interspersed among bony trabeculae consistent with an osseous cavernous hemangioma.
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Affiliation(s)
- Seanna R Grob
- a Department of Ophthalmology , Harvard Medical School , Boston , MA , USA.,b Orbit and Oculoplastic Surgery, Gavin Herbert Eye Center , University of California, Irvine , Irvine , CA , USA
| | - Natalie Wolkow
- a Department of Ophthalmology , Harvard Medical School , Boston , MA , USA.,c David G. Cogan Laboratory of Ophthalmic Pathology , Massachusetts Eye and Ear Infirmary , Boston , MA , USA.,d Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , MA , USA
| | - Frederick A Jakobiec
- a Department of Ophthalmology , Harvard Medical School , Boston , MA , USA.,c David G. Cogan Laboratory of Ophthalmic Pathology , Massachusetts Eye and Ear Infirmary , Boston , MA , USA
| | - Daniel R Lefebvre
- a Department of Ophthalmology , Harvard Medical School , Boston , MA , USA.,d Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , MA , USA
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18
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Abstract
BACKGROUND Endoscopic dacryocystorhinostomies (eDCRs) show patency rates between 81% and 94%. However, dacryocystorhinostomy (DCR) failure and the need for revision remain a significant challenge. One of the principal challenges in revision eDCR is the need to surgically identify the correct osteotomy site and maintain long-term patency in the setting of previously instrumented and potentially scarred tissue. At the same time, the surgeon must assume that the blood supply to the commonly described anterior and posteriorly pedicled flaps has been compromised. OBJECTIVE The objective of the study is to describe a novel flap technique for revision eDCR. METHODS The superior based mucosal flap is a novel technique that provides a vascularized mucosa preserving technique in revision eDCR despite previous instrumentation of the lacrimal system. This technique provides wide exposure of the revision osteotomy site while simultaneously allowing a viable mucosal flap to be replaced at the conclusion of the procedure, thereby minimizing bone exposure and cicatricial restenosis. RESULTS The authors have utilized this technique in 13 procedures with 100% positive identification of the lacrimal sac, a 0% complication rate, and a 100% success rate after a mean follow-up of 26.93 ± 10.33 months (range 6-35 months). CONCLUSION The eDCR using the superior pedicled mucosal flap provides excellent exposure of the maxillary bone and the lacrimal sac. This method preserves vascularity of the flap using a superiorly based pedicle which is typically inviolate during both open and endoscopic primary DCR. The mucosal flap can then be replaced, thereby minimizing bone exposure and optimizing patency.
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Affiliation(s)
- Sarina K Mueller
- a Department of Otolaryngology , Massachusetts Eye and Ear, Harvard Medical School , Boston , MA , USA.,b Department of Otolaryngology , University of Erlangen-Nuremberg , Erlangen , Germany
| | - Suzanne K Freitag
- c Department of Ophthalmology , Massachusetts Eye and Ear, Harvard Medical School , Boston , MA , USA
| | - Daniel R Lefebvre
- c Department of Ophthalmology , Massachusetts Eye and Ear, Harvard Medical School , Boston , MA , USA
| | - Nahyoung G Lee
- c Department of Ophthalmology , Massachusetts Eye and Ear, Harvard Medical School , Boston , MA , USA
| | - Benjamin S Bleier
- a Department of Otolaryngology , Massachusetts Eye and Ear, Harvard Medical School , Boston , MA , USA
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19
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Rasool N, Lefebvre DR, Latina MA, Dunn IF, Santagata S, Freitag SK, Cestari DM. Orbital leiomyosarcoma metastasis presenting prior to diagnosis of the primary tumor. Digit J Ophthalmol 2018; 23:22-26. [PMID: 29403338 DOI: 10.5693/djo.02.2017.02.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Leiomyosarcomas, neoplasms of smooth muscle, are rarely found within the orbit. Orbital leiomyosarcoma may be primary, metastatic, or secondary to radiation. When they are metastatic, patients almost exclusively have a history of a primary leiomyosarcoma, often occurring in the spermatic cord, skin, gastrointestinal tract, or the uterus. We present the case of 48-year-old woman who presented with a metastatic orbital leiomyosarcoma, which was identified before the primary tumor.
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Affiliation(s)
- Nailyn Rasool
- Edward Harkness Eye Institute, Columbia University, New York
| | - Daniel R Lefebvre
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Mark A Latina
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Ian F Dunn
- Department of Neurosurgery. Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sandro Santagata
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Suzanne K Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
| | - Dean M Cestari
- Department of Ophthalmology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts
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20
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Mueller SK, Miyake MM, Lefebvre DR, Freitag SK, Bleier BS. Long-term impact of endoscopic orbital decompression on sinonasal-specific quality of life. Laryngoscope 2017; 128:785-788. [PMID: 28944477 DOI: 10.1002/lary.26812] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2017] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Endoscopic orbital decompression (EOD) is the workhorse surgical intervention for severe thyroid eye disease in Graves disease. Although EOD is a safe and effective procedure, the objective of this study is to determine the impact of orbital decompression on long-term sinonasal-pecific quality of life. METHODS Retrospective study of 27 patients who underwent EOD by a single surgeon. The primary endpoint was change in preoperative 22-item Sinonasal Outcomes Test (SNOT-22) score at a minimum of 1 year. The secondary endpoint was to determine whether the performance of septoplasty for surgical access in patients without nasal obstruction impacted domain 1 (i.e., rhinologic domain) and total SNOT-22 scores. RESULTS The mean follow-up was 25.7 ± 11.4 months. Domain 1 scores significantly increased at the first postoperative visit (P ≤ 0.01) and returned to baseline values between 1 and 3 months. At 1 year, significant improvements in both total score and domain 4 and 5 (psychological and sleep dysfunction, respectively) scores were seen (P < 0.01 for all scores). Septoplasty was not associated with a significant change in SNOT-22 score at 1 year (P = 0.48). CONCLUSION Endoscopic orbital decompression is associated at 1 year with a significant improvement in sinonasal-specific quality of life, which is driven by the psychological and sleep dysfunction domains. Adjunctive septoplasty has no significant impact on SNOT-22 scores. LEVEL OF EVIDENCE 4. Laryngoscope, 128:785-788, 2018.
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Affiliation(s)
- Sarina K Mueller
- Department of Otolaryngology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Marcel M Miyake
- Department of Otolaryngology, Santa Casa de Sao Paulo School of Medical Sciences, Sao Paulo, Brazil.,Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Daniel R Lefebvre
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Suzanne K Freitag
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Benjamin S Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, U.S.A
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21
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Mueller SK, Freitag SK, Lefebvre DR, Bleier BS. Endoscopic DCR using bipedicled interlacing mucosal flaps. Laryngoscope 2017; 128:794-797. [PMID: 28786234 DOI: 10.1002/lary.26730] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Accepted: 05/09/2017] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Obstruction of the nasolacrimal duct is a relatively common condition that affects patients of all ages, races, and sexes. The surgical gold standard for complete nasolacrimal duct obstruction and dacryocystitis is dacryocystorhinostomy (DCR). The purpose of this study was to describe a novel, bipedicled interlacing mucosal sparing flap technique for endoscopic DCR (eDCR). METHODS A posteriorly based mucosal flap over the fundus is combined with a novel, anteriorly based mucosal flap over the intraosseus portion of the nasolacrimal duct (NLD). This exposes a wide area of the maxillary bone, allowing for exposure and identification of the NLD/sac complex in a safer, more inferior position. The interlacing mucosal flaps may be replaced at the conclusion of the procedure, thereby minimizing bone exposure and maintaining excellent long-term patency. RESULTS The authors have utilized this technique in 55 procedures with 100% positive identification of the NLD and lacrimal sac, 0% complication rate, 100% anatomical patency rate, and 96.4% success rate after a minimal follow-up of 6 months. DISCUSSION The bipedicled interlacing flap technique for eDCR provides for safe and reproducible identification of the NLD and lacrimal sac while minimizing bone exposure and restenosis rate. CONCLUSION The bipedicled interlacing flap technique for eDCR provides for safe and reproducible identification of the NLD and lacrimal sac while minimizing bone exposure and restenosis rate. LEVEL OF EVIDENCE NA. Laryngoscope, 128:794-797, 2018.
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Affiliation(s)
- Sarina K Mueller
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A.,Department of Otolaryngology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Suzanne K Freitag
- Department of Ophthalmology Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Daniel R Lefebvre
- Department of Ophthalmology Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
| | - Benjamin S Bleier
- Department of Otolaryngology, Massachusetts Eye and Ear, Harvard Medical School, Boston, Massachusetts, U.S.A
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22
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Miyake MM, Gregorio LL, Freitag SK, Lefebvre DR, Gray ST, Holbrook EH, Bleier BS. Impact of endoscopic dacryocystorhinostomy on sinonasal quality of life. Am J Rhinol Allergy 2017; 30:189-91. [PMID: 27657894 DOI: 10.2500/ajra.2016.30.4332] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
BACKGROUND Dacryocystorhinostomy (DCR) is the criterion standard of surgical treatment for complete nasolacrimal obstruction and dacryocystitis. There has been an expansion in the indication of the endonasal DCR (eDCR), but the impact of surgical manipulating an otherwise healthy nasal mucosa on postoperative sinonasal quality of life remains unknown. The purpose of this study was to determine whether patients who underwent eDCR experienced any decrement in sinonasal quality of life. METHODS A retrospective chart review of 44 patients who underwent eDCR between June 2012 and May 2015. The primary outcome was the total and nasal-specific domain 1 scores of the disease specific validated Sino-Nasal Outcomes Test 22. Preoperative scores were compared with the postoperative scores on days 0-30, 30-90, and 90-180 visits. A subgroup analysis of patients without nasal symptoms who underwent concomitant nasal surgical procedures was also performed. RESULTS A statistically significant increase was observed between the preoperative score and the first postoperative score (days 0-30) in both total (7.5 [0-44] to 24 [0-51], median [interquartile range]) and domain 1 (2.5 [0-11] to 9 [0-18]) scores (p = 0.0066 and p = 0.0001, respectively). In contrast, there was no statistically significant difference between the pre- and postoperative scores on days 30-90 or 90-180. Similar results were observed in the subgroup analysis. CONCLUSION Analysis of our findings indicated that, in general, eDCR was well tolerated by patients and nasal symptom scores returned to baseline values within 30-90 days of surgery. The concomitant performance of septoplasty in the setting of asymptomatic septal deviation did not confer any long-term improvement in symptoms of nasal obstruction.
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Affiliation(s)
- Marcel M Miyake
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
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23
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Affiliation(s)
- Seanna Grob
- Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Daniel R Lefebvre
- Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.,Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts.,Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts
| | - Nora Laver
- Ophthalmic Pathology, Department of Ophthalmology, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Mary K Daly
- Department of Ophthalmology, Veterans Affairs Boston Healthcare System, Jamaica Plain, Massachusetts.,Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts.,Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
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24
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Lin GC, Freitag SK, Kocharyan A, Yoon MK, Lefebvre DR, Bleier BS. Comparative techniques of medial rectus muscle retraction for endoscopic exposure of the medial intraconal space. Am J Rhinol Allergy 2017; 30:226-9. [PMID: 27216355 DOI: 10.2500/ajra.2016.30.4307] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE The medial rectus muscle (MRM) is the medial boundary to the intraconal space of the orbit, and retraction of the MRM is oftentimes necessary for endoscopic removal of intraconal tumors, e.g., orbital hemangioma. We evaluated each of the reported methods of MRM retraction for endoscopic orbital surgery and quantified the degree of intraconal exposure conferred by each method. METHODS Eight orbits from four cadaver heads were dissected. In each orbit, medial orbital decompression was performed and the MRM was retracted by using four previously described techniques: (1) external MRM retraction at the globe insertion point by using vessel loop (external group), (2) transseptal MRM retraction by using vessel loop (transseptal group), (3) transchoanal retraction of the MRM by using vessel loop (choanal group), and (4) transseptal four-handed technique by using double ball retraction by a second surgeon (transseptal double ball group). The length, height, and area of exposure of the medial intraconal space were quantified and compared. RESULTS The average ± standard deviation (SD) anterior-posterior exposures for the external group, transseptal group, and transseptal double ball group were 17.51 ± 3.39 mm, 16.59 ± 4.16 mm, and 18.0 ± 15.25 mm, respectively. The choanal group provided significantly less exposure (12.39 ± 3.44 mm, p = 0.049) than the other groups. The average ± SD vertical exposures for the transseptal group, choanal group, and transseptal double ball group were 12.53 ± 4.38 mm, 13.05 ± 5.86 mm, and 13.57 ± 3.74 mm, respectively. The external group provided significantly less exposure (4.51 ± 1.56 mm, p = 0.0072) than the other groups. The transseptal and transseptal double ball groups provided the greatest total access by surface area (58.88 ± 26.96 mm(2) and 62.94 ± 34.74 mm(2), respectively) compared with the external and choanal groups (34.82 ± 23.37 mm(2) and 43.10 ± 23.68 mm(2), respectively). Although the transseptal trajectory of MRM retraction was optimal, the difference in total area of exposure between the static vessel loop retraction and the dynamic, four-handed technique with double ball instrument retraction was not significant. Of note, the exposure provided by the choanal technique required the surgeon to work both above and below the muscle. CONCLUSION Retraction of the MRM toward the choanae provided the least length of exposure, and external retraction exposed the least height and total area. Transseptal MRM retraction was most favorable and provided the largest endoscopic corridor to the medial intraconal space. A four-handed approach for endoscopic intraconal surgery of the orbit may offer advantages in dynamic adjustments in retraction.
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Affiliation(s)
- Giant C Lin
- Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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25
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Abstract
The authors report their experience with orbital exenteration surgery at one academic institution over a 10-year period and review the literature. This retrospective cohort study monitored outcomes of all patients who underwent orbital exenteration surgery at Massachusetts Eye and Ear Infirmary between January 2003 and January 2013. Patients with no follow-up data or survival data were excluded from the study. The main outcome measures were surgical complications, disease status of surgical margins, need for adjuvant treatment, local recurrence, metastases and survival. 23 patients with malignancy and 2 with mucormycosis met inclusion criteria for the study. Surgical procedures included non-lid sparing total exenteration (44%), lid-sparing total exenteration (32%), non-lid sparing partial exenteration (8%) and lid-sparing partial exenteration (16%). 44% underwent additional extra-orbital procedures. Survival rates were 72% at 1 year, 48% at 3 years, and 37% at 5 years. Of patients with malignancies, 48% had clear margins after exenteration. There was no statistically significant difference in survival between patients with negative surgical margins compared to positive margins (p = 0.12). Mortality was highest in patients with melanoma (85.7%) and lowest in patients with non-squamous cell lid malignancies (0%). Our study suggests that the type of disease has a much greater impact on the survival of patients undergoing exenteration surgery than the type of exenteration surgery or the disease status of surgical margins. Patients with non-squamous cell lid malignancies and localized orbital disease have the best prognosis for tumor eradication from this radical and highly disfiguring surgery.
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Affiliation(s)
- Sonali T Nagendran
- a Department of Ophthalmology , Frimley Park Hospital , Surrey , United Kingdom
| | - N Grace Lee
- b Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Harvard Medical School , Boston , Massachusetts , USA
| | - Aaron Fay
- b Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Harvard Medical School , Boston , Massachusetts , USA
| | - Daniel R Lefebvre
- b Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Harvard Medical School , Boston , Massachusetts , USA
| | - Francis C Sutula
- b Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Harvard Medical School , Boston , Massachusetts , USA
| | - Suzanne K Freitag
- b Department of Ophthalmology, Massachusetts Eye and Ear Infirmary , Harvard Medical School , Boston , Massachusetts , USA
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26
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Abstract
The aim of this article is to validate the accuracy of Facial Assessment by Computer Evaluation (FACE) program in eyelid measurements. Sixteen subjects between the ages of 27 and 65 were included with IRB approval. Clinical measurements of upper eyelid margin reflex distance (MRD1) and inter-palpebral fissure (IPF) were obtained. Photographs were then taken with a digital single lens reflex camera with built-in pop-up flash (dSLR-pop) and a dSLR with lens-mounted ring flash (dSLR-ring) with the cameras upright, rotated 90, 180, and 270 degrees. The images were analyzed using both the FACE and ImageJ software to measure MRD1 and IPF.Thirty-two eyes of sixteen subjects were included. Comparison of clinical measurement of MRD1 and IPF with FACE measurements of photos in upright position showed no statistically significant differences for dSLR-pop (MRD1: p = 0.0912, IPF: p = 0.334) and for dSLR-ring (MRD1: p = 0.105, IPF: p = 0.538). One-to-one comparison of MRD1 and IPF measurements in four positions obtained with FACE versus ImageJ for dSLR-pop showed moderate to substantial agreement for MRD1 (intraclass correlation coefficient = 0.534 upright, 0.731 in 90 degree rotation, 0.627 in 180 degree rotation, 0.477 in 270 degree rotation) and substantial to excellent agreement in IPF (ICC = 0.740, 0.859, 0.849, 0.805). In photos taken with dSLR-ring, there was excellent agreement of all MRD1 (ICC = 0.916, 0.932, 0.845, 0.812) and IPF (ICC = 0.937, 0.938, 0.917, 0.888) values. The FACE program is a valid method for measuring margin reflex distance and inter-palpebral fissure.
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Affiliation(s)
- Catherine J Choi
- a Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
- b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA
| | - Daniel R Lefebvre
- a Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
- b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA
| | - Michael K Yoon
- a Ophthalmic Plastic Surgery , Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA
- b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA
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Abstract
DCR is the treatment of choice for NLDO. External DCR has remained the standard approach since the 1890s. With advances in technique and technology, and more otolaryngologists and ophthalmologists performing endoscopic DCR, more studies have been conducted, some with equivalent success rates between the 2 approaches. Endoscopic endonasal DCR offers the advantages of avoiding a skin incision with similar success rates with experienced surgeons. However, the technique necessitates more surgical equipment, and has a steep learning curve. Both approaches have low complication rates and serious complications are very rare. The decision for the type of approach to use depends on the surgeon’s experience, the patient’s preference or concerns, and the resources available within a particular health system.
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Lefebvre DR, Dhar S, Lee I, Allard F, Freitag SK. External dacryocystorhinostomy outcomes in patients with a history of dacryocystitis. Digit J Ophthalmol 2015; 21:1-22. [PMID: 27330467 DOI: 10.5693/djo.01.2014.08.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
PURPOSE To investigate nonidiopathic causes of external dacryocystorhinostomy (DCR) failure. METHODS The medical records of all patients with acute or chronic dacryocystitis who underwent external dacryocystorhinostomy performed by the senior author over a 5-year period were retrospectively reviewed, with attention to microbiology, pathology, and associated medical and history. RESULTS A total of 52 lacrimal systems of 49 patients were included, with a minimum follow-up of 2 months (average, 15.5 months). Surgical success was achieved in 42 systems (87%). Of 7 failures, 6 had a condition potentially associated with an increased risk of failure, including MRSA infection, Gram-negative infection, rhinosinusitis, lymphoma, inflammatory bowel disease, and early loss of lacrimal stents. CONCLUSIONS External DCR is a successful procedure for the treatment of nasolacrimal obstruction associated with dacryocystitis. Various factors may affect surgical success, and awareness of these factors may enable better patient counseling and surgical planning.
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Affiliation(s)
- Daniel R Lefebvre
- Division of Ophthalmic Plastic Surgery, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts;; Department of Ophthalmology, Harvard Medical School, Boston
| | - Sonya Dhar
- Department of Ophthalmology, New York University / New York Harbor Healthcare System, New York, New York;; Department of Ophthalmology, Moran Eye Center, Salt Lake City, Utah
| | - Irene Lee
- Division of Ophthalmology, Rhode Island Hospital, The Warren Alpert Medical School at Brown University, Providence
| | - Felicia Allard
- Department of Pathology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston
| | - Suzanne K Freitag
- Division of Ophthalmic Plastic Surgery, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts;; Department of Ophthalmology, Harvard Medical School, Boston
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Trief D, Gray ST, Jakobiec FA, Durand ML, Fay A, Freitag SK, Lee NG, Lefebvre DR, Holbrook E, Bleier B, Sadow P, Rashid A, Chhabra N, Yoon MK. Invasive fungal disease of the sinus and orbit: a comparison between mucormycosis and Aspergillus. Br J Ophthalmol 2015; 100:184-8. [PMID: 26112869 DOI: 10.1136/bjophthalmol-2015-306945] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2015] [Accepted: 05/30/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND/AIMS Invasive fungal infections of the head and neck are rare life-threatening infections where prompt diagnosis and intervention is critical for survival. The aim of this study is to determine the clinical characteristics and outcomes of invasive fungal disease of the sinus and orbit, and to compare mucormycosis and Aspergillus infection. METHODS A retrospective review was conducted from a single tertiary care eye and ear hospital over 20 years (1994-2014). Twenty-four patients with a confirmed pathological diagnosis of invasive fungal disease of the sinus and/or orbit were identified and their medical records were reviewed. The main outcome measures were type of fungus, location of disease, mortality and visual outcome. RESULTS Patients with orbital involvement had a higher mortality and higher likelihood of mucormycosis infection compared with those with sinus-only disease (78.6% vs 20%, p=0.01; 86% vs 30%, p=0.01, respectively). Patients with mucormycosis had a higher mortality (71%) than patients with Aspergillus (29%); however, this was not statistically significant (p=0.16). All patients with orbital involvement and/or mucormycosis infections were immunosuppressed or had inadequately controlled diabetes, and had a cranial neuropathy or ocular motility dysfunction. All five post-transplant patients with orbital infections died, while the two transplant patients with sinus infections survived. CONCLUSIONS Patients with orbital fungal infections are more likely to be infected with mucormycosis compared with Aspergillus and have a higher mortality compared with infections sparing the orbit. History of transplant portends a dismal prognosis in orbital infections. Invasive fungal disease should be considered in any immunocompromised patient presenting with a new cranial neuropathy or ocular motility abnormality.
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Affiliation(s)
- Danielle Trief
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Stacey T Gray
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Frederick A Jakobiec
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Marlene L Durand
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Aaron Fay
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Suzanne K Freitag
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - N Grace Lee
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Daniel R Lefebvre
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
| | - Eric Holbrook
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Benjamin Bleier
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Sadow
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Alia Rashid
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA
| | - Nipun Chhabra
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Otolaryngology, Harvard Medical School, Boston, Massachusetts, USA
| | - Michael K Yoon
- Massachusetts Eye and Ear Infirmary, Boston, Massachusetts, USA Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
The orbital branch of the infraorbital artery, a key vascular structure that is not universally noted in orbital textbooks and atlases, is clinically significant, since injury to it can result in perioperative hemorrhage. We conducted a cadaver dissection to document its presence, measure its location, and evaluate it histopathologically. It was present in 8 of 9 orbits and was a mean distance of 16.6 mm (range 10-23) from the inferior orbital rim. In half of the specimens, there were 2 separate structures seen. Histopathology confirmed these structures to be neurovascular bundles.
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Affiliation(s)
- Avni V Patel
- Department of Ophthalmology, Harvard Medical School , Boston, Massachusetts , USA
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Tiedemann LM, Lefebvre DR, Wan MJ, Dagi LR. Iatrogenic inferior oblique palsy: intentional disinsertion during transcaruncular approach to orbital fracture repair. J AAPOS 2014; 18:511-4. [PMID: 25266842 DOI: 10.1016/j.jaapos.2014.06.005] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2014] [Revised: 06/16/2014] [Accepted: 06/20/2014] [Indexed: 11/29/2022]
Abstract
Hypotropia following orbital fracture repair is traditionally attributed to residual tissue entrapment, scarring, direct muscle injury, or damage to the branches of the oculomotor nerve serving the inferior oblique or inferior rectus muscles. We present a case of acquired hypotropia and incyclotropia that occurred following repair of an orbital fracture involving the floor and medial wall. In order to enable adequate visualization and treatment of the combined fractures, access via a transcaruncular approach and disinsertion of the inferior oblique muscle at its origin was necessary. Whereas the possibility of inferior oblique paresis due to repair of an orbital fracture via the transcaruncular approach has received some acknowledgment, there are no prior reports in the ophthalmic literature. Strabismus surgeons should be aware of this possibility when planning surgical correction of hypotropia and incyclotropia in similar cases.
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Affiliation(s)
- Laura M Tiedemann
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts
| | - Daniel R Lefebvre
- Division of Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Michael J Wan
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts
| | - Linda R Dagi
- Department of Ophthalmology, Boston Children's Hospital, Boston, Massachusetts; Department of Ophthalmology, Harvard Medical School, Boston, Massachusetts.
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Lefebvre DR, Mandeville JT, Yonekawa Y, Arroyo JG, Torun N, Freitag SK. A Case Series and Review of Bisphosphonate-associated Orbital Inflammation. Ocul Immunol Inflamm 2014; 24:134-9. [PMID: 25153041 DOI: 10.3109/09273948.2014.942747] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
PURPOSE To report the largest series of new cases to date of bisphosphate-associated orbital inflammation. METHODS A retrospective case review of patients with orbital inflammation following treatment with systemic bisphosphonate. RESULTS Six patients over an 18-month period (2 males, 4 females) with an average age of 62.2 years had onset of orbital inflammatory symptoms 1-11 days after intravenous bisphosphonate infusion or, in 1 case, 4 weeks after initiation of oral bisphosphonate therapy. Imaging revealed diffuse orbital involvement in 3 cases, isolated lateral rectus muscle involvement in 2 cases, and superior rectus-levator involvement in 1 case. Two patients' symptoms resolved spontaneously within 2 weeks, and 3 responded rapidly and completely to corticosteroid therapy. The 1 patient on oral bisphosphonate had a slower but complete response to corticosteroid treatment. CONCLUSION Clinicians should be aware of the association between acute orbital inflammation and recent treatment with systemic bisphosphonate medication.
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Affiliation(s)
- Daniel R Lefebvre
- a Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA .,b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA
| | - John T Mandeville
- b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA .,c Eye Health Services, Inc. , Quincy , Massachusetts , USA
| | - Yoshihiro Yonekawa
- b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA
| | - Jorge G Arroyo
- b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA .,d Beth Israel Deaconess Medical Center, Division of Ophthalmology , Boston , Massachusetts , USA
| | - Nurhan Torun
- b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA .,d Beth Israel Deaconess Medical Center, Division of Ophthalmology , Boston , Massachusetts , USA
| | - Suzanne K Freitag
- a Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary , Boston , Massachusetts , USA .,b Department of Ophthalmology , Harvard Medical School , Boston , Massachusetts , USA
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Abstract
PURPOSE To report the novel use of a sinus microdebrider for the removal of tissue during orbital surgery. METHODS This retrospective study reviewed the logs of 3 surgeons to identify patients who required orbital surgery during which the surgeon chose to use a sinus microdebrider with an open sky technique as a means of removing portions of the orbital tissue. Collected data included patient demographics, clinical examinations, pathologic diagnoses, radiologic studies, operative reports and, when available, photographs and intra-operative video. RESULTS Three patients were identified as having undergone orbital surgery assisted by the use of a sinus microdebrider. The first patient had an extensive, recurrent left orbital myxoid tumor. Debulking of this gelatinous, infiltrative mass was aided by the combined suction and cutting action of the microdebrider. Two cases involved orbital exenteration for infiltrative sino-orbital fungus infection resulting in a blind eye and frozen globe. Removal of orbital apical tissue during exenteration surgery was facilitated with the microdebrider. CONCLUSIONS The characteristics of the sinus microdebrider make it a useful adjunct for orbital surgery, particularly in situations where tissue may be difficult to grasp and excise. Caution should be exercised whenever using this electrically powered tool due to its potential for rapid tissue destruction. Therefore, the microdebrider should only be used in cases in which there is little risk of damage to essential orbital structures.
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Affiliation(s)
- Suzanne K Freitag
- Ophthalmic Plastic Surgery Service, Massachusetts Eye and Ear Infirmary, Harvard Medical School , Boston, Massachusetts 02114 , USA
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Jakobiec FA, Rai R, Lefebvre DR. Papillary hidradenoma of the eyelid margin: clinical and immunohistochemical observations further supporting an apocrine rather than an eccrine origin. Surv Ophthalmol 2014; 59:540-7. [PMID: 24661803 DOI: 10.1016/j.survophthal.2014.01.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 12/26/2013] [Accepted: 01/08/2014] [Indexed: 11/18/2022]
Abstract
A 46-year-old woman was evaluated for a "recurring papilloma" of the left medial upper eyelid margin. Beneath the papillary lesion medial to the punctum was a 5-mm diameter cutaneous mass thought to be cystic. After excisional biopsy, histopathologic analysis documented the presence of an epidermal keratinizing squamous papilloma surmounting a circumscribed dermal papillary hidradenoma composed of deeply eosinophilic columnar cells. Additionally, there was intraductal proliferation of tumor extending toward a subclinical poral opening through the epidermis. Immunohistochemistry proved the apocrine nature of the benign, non-cystic lesion by virtue of its nuclear androgen receptor and cytoplasmic gross-cystic disease fluid protein-15 positivity, along with its smooth muscle actin-positive myoepithelial layer. This and prior cases establish that apocrine tumors, both benign and malignant, are strictly localized at or near the eyelid margin where only apocrine glands are found. These tumors are more often papillary than solid adenomas, and most exceptionally can be malignant. We review the differential diagnosis of simulating eccrine eyelid tumors. We recommend wide local excision for benign lesions, in view of possible intraductal extension that can be eccentric to the main tumor and the miniscule potential for malignant transformation.
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Affiliation(s)
- Frederick A Jakobiec
- Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts.
| | - Ruju Rai
- Department of Ophthalmology, David G. Cogan Laboratory of Ophthalmic Pathology, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
| | - Daniel R Lefebvre
- Department of Ophthalmology, Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Boston, Massachusetts; Harvard Medical School, Boston, Massachusetts
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Bleier BS, Lefebvre DR, Freitag SK. Endoscopic orbital floor decompression with preservation of the inferomedial strut. Int Forum Allergy Rhinol 2013; 4:82-4. [PMID: 24124099 DOI: 10.1002/alr.21231] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2013] [Revised: 08/20/2013] [Accepted: 09/03/2013] [Indexed: 11/12/2022]
Abstract
BACKGROUND Medial and inferior orbital decompression is most commonly performed in the setting of dysthyroid orbitopathy. Diplopia represents the most common complication and may be minimized through the preservation of a bony inferomedial strut (IMS). Historically, this has required a transconjunctival approach due to the technical demands of performing an isolated orbital floor decompression using endoscopic instrumentation. Here we describe a novel technique of a purely endoscopic orbital floor decompression with reliable preservation of the IMS. METHODS Description of a novel surgical technique for endoscopic orbital floor decompression with IMS preservation using frontal sinus instrumentation visualized by a 70-degree endoscope. RESULTS We have successfully used this technique in 12 orbits with 100% preservation of the bony inferomedial strut and no complications. The extent of decompression and width of the residual strut may be fine tuned as needed to optimize results. CONCLUSION Orbital floor decompression with IMS preservation may be reliably performed using purely endoscopic techniques. Successful completion of this procedure requires the adaptation of standard frontal sinus instrumentation to the maxillary sinus roof and thus may be readily mastered by any endoscopic surgeon comfortable with frontal sinus techniques.
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Affiliation(s)
- Benjamin S Bleier
- Department of Otology and Laryngology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, MA
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Shah M, Lee G, Lefebvre DR, Kronberg B, Loomis S, Brauner SC, Turalba A, Rhee DJ, Freitag SK, Pasquale LR. A cross-sectional survey of the association between bilateral topical prostaglandin analogue use and ocular adnexal features. PLoS One 2013; 8:e61638. [PMID: 23650502 PMCID: PMC3641120 DOI: 10.1371/journal.pone.0061638] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2012] [Accepted: 03/11/2013] [Indexed: 11/18/2022] Open
Abstract
We studied the relation between prostaglandin analogue use and ocular adnexal features. We used a prospective, cross-sectional study involving 157 current, 15 past, and 171 never users of prostaglandin analogues. Patients 50 years of age or older and without conditions affecting ocular adnexal anatomy underwent glaucoma medication use history, external digital photography and systematic external adnexal exam. Two masked readers assessed the digital photos for upper lid dermatochalasis and lower lid steatoblepharon using a validated grading scheme. Another masked clinical examiner also assessed upper lid ptosis, levator muscle function, and inferior scleral show. We performed ordinal logistic regression analysis accounting for multiple covariates to assess the relation between prostaglandin analogue use and adnexal features. Multivariable analyses indicated there was a 230-fold increased risk of incremental involution of dermatochalasis (odds ratio (OR) = 2.30; 95% confidence interval (CI) 1.43–3.69; p = 5.44E-04) and a 249-fold increased risk of incremental loss of lower lid steatoblepharon (OR = 2.49; 95% CI, 1.54–4.03; p = 1.98E-04) associated with current prostaglandin analogue use (bimatoprost 0.03%, travoprost 0.005%, or latanoprost 0.004%) versus prostaglandin analogue never or past users. Upper lid ptosis (OR = 4.04; 95% CI, 2.43–6.72; p = 7.37E-08), levator dysfunction (OR = 7.51; 95% CI, 3.39–16.65; p = 6.74E-07) and lower lid retraction (OR = 2.60; 95% CI, 1.58–4.28; p = 1.72E-04) were highly associated with current prostaglandin analogue use versus prostaglandin analogue never or past users. The associations between prostaglandin analogue use and deepening of the upper lid sulci and between prostaglandin analogue use and loss of inferior periorbital fat are confirmed in this multivariable analysis. The associations between prostaglandin analogue use and levator muscle dysfunction and between prostaglandin analogue use and upper lid ptosis represent significant side effects that could impact visual function in glaucoma patients.
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Affiliation(s)
- Mamta Shah
- Department of Ophthalmology, Boston University School of Medicine, Boston, Massachusetts, United States of America.
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Papakostas TD, Lee NG, Lefebvre DR, Barshak MB, Freitag SK. Endogenous panophthalmitis with orbital cellulitis secondary to Escherichia coli. Clin Exp Ophthalmol 2013; 41:716-8. [PMID: 23432793 DOI: 10.1111/ceo.12094] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2013] [Accepted: 02/04/2013] [Indexed: 11/27/2022]
Affiliation(s)
- Thanos D Papakostas
- Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Harvard Medical School, Boston, Massachusetts, USA
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Abstract
Epiphora is a common problem seen by the ophthalmologist. There are numerous etiologies of a watering eye, and the underlying diagnosis is not always clear. A variety of in-office examination techniques and procedures exist to aid with diagnosis and determination of appropriate therapy, but sometimes the diagnosis remains elusive, or an instituted therapy fails. Lacrimal imaging, particularly in these cases, can be helpful in assessing the function and anatomy of the lacrimal drainage system. This review serves to examine the literature of the last 10 years concerning imaging of the lacrimal drainage system.
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Affiliation(s)
- Daniel R Lefebvre
- Division of Ophthalmic Plastic Surgery, Department of Ophthalmology, Massachusetts Eye and Ear Infirmary, Boston, MA 02114, USA.
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39
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Affiliation(s)
- Daniel R Lefebvre
- Ophthalmic Plastic Surgery, Massachusetts Eye and Ear Infirmary, Harvard Medical School
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40
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Lefebvre DR, Strande LF, Hewitt CW. An Enzyme-Mediated Assay to Quantify Inoculation Volume Delivered by Suture Needlestick Injury: Two Gloves Are Better Than One. J Am Coll Surg 2008; 206:113-22. [DOI: 10.1016/j.jamcollsurg.2007.06.282] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2007] [Revised: 05/30/2007] [Accepted: 06/06/2007] [Indexed: 11/16/2022]
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Lefebvre DR, Tai C, Matthews MS, Gordon CR, Strande LF, Marra SW, Hewitt CW. Graft heart rates may grossly indicate development of immunotolerance induced by isolated vascularized bone marrow transplantation. FASEB J 2007. [DOI: 10.1096/fasebj.21.5.a185-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel R. Lefebvre
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon AvenueCamdenNJ08103
| | - Chau Tai
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon AvenueCamdenNJ08103
| | - Matthews S. Matthews
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon AvenueCamdenNJ08103
| | - Chad R. Gordon
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon AvenueCamdenNJ08103
| | - Louise F. Strande
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon AvenueCamdenNJ08103
| | - Steven W. Marra
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon AvenueCamdenNJ08103
| | - Charles W. Hewitt
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon AvenueCamdenNJ08103
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Gordon CR, Matthews MS, Lefebvre DR, Strande LF, Marra SW, Guglielmi M, Hollenberg SM, Hewitt CW. A new modified technique for heterotopic femoral heart transplantation in rats. J Surg Res 2007; 139:157-63. [PMID: 17349659 DOI: 10.1016/j.jss.2006.12.543] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2006] [Revised: 12/11/2006] [Accepted: 12/13/2006] [Indexed: 10/23/2022]
Abstract
BACKGROUND Abbott developed the first experimental accessory heart transplant rat model in 1964. This intra-abdominal model required a labor-intensive aortic anastomosis. In 1971, Heron modified the operation by using sutureless cervical vessel anastomoses. Rao and Lisitza developed a femoral heart accessory transplant model in 1985. Our goal was to improve this femoral model for the study of cardiac transplantation between both syngeneic and allogeneic rats. METHODS ACI and Lewis rats weighing 150 to 350 g were used as donors and recipients (n = 12). The left common carotid and left pulmonary arteries were anastomosed to the femoral artery and vein in an end-to-end fashion, respectively. Improved modifications included the use of hemostatic vessel clips, heparinization of both donor and recipient, a ventricular prolene stay-suture for secure graft placement, and transfemoral echocardiography (TFE). Total operative time averaged 61 +/- 12 minutes. RESULTS Femoral accessory transplanted hearts (FATHs) allowed easier pulse palpation and access for TFE versus previously described cervical and intra-abdominal models. This modification allows precise detection of acute graft rejection (AGR) and is defined as absent ventricular contraction in the presence of anastomostic patency. CONCLUSIONS Our new modified technique for heterotopic femoral heart transplantation in rats is a relatively easily learned and reproduced procedure that allows superior allograft access for palpation and improved echocardiographic assessment. Femoral heterotopic heart transplantation remains an effective model for allograft transplantation study.
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Affiliation(s)
- Chad R Gordon
- Division of Surgical Research, Department of Surgery, University of Medicine and Dentistry in New Jersey, Robert Wood Johnson Medical School, Cooper University Hospital, Camden, New Jersey, USA.
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Lefebvre DR, Tai C, Matthews M, Strande LF, Marra S, Hewitt CW. Hemosiderin‐laden macrophages: a marker for sub‐clinical graft‐versus‐host‐disease (GVHD) after bone marrow transplantation. FASEB J 2007. [DOI: 10.1096/fasebj.21.6.a767-a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Daniel R. Lefebvre
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon Avenue, 3rd FloorCamdenNJ08103
| | - Chau Tai
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon Avenue, 3rd FloorCamdenNJ08103
| | - Martha Matthews
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon Avenue, 3rd FloorCamdenNJ08103
| | - Louise F. Strande
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon Avenue, 3rd FloorCamdenNJ08103
| | - Steven Marra
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon Avenue, 3rd FloorCamdenNJ08103
| | - Charles W. Hewitt
- SurgeryUMDNJ‐RWJMS/Cooper University HospitalEducation & Research Building, 401 Haddon Avenue, 3rd FloorCamdenNJ08103
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Gordon CR, Lefebvre DR, Matthews MS, Strande LF, Marra SW, Guglielmi M, Skaf J, Hollenberg SM, Hewitt CW. Pulse doppler and M-mode to assess viability of cardiac allografts using heterotopic femoral heart transplantation in rats. Microsurgery 2007; 27:240-4. [PMID: 17492641 DOI: 10.1002/micr.20343] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Noninvasive assessment of heterotopic heart transplants using Doppler echocardiography was first described in two patients by Allen at Stanford in 1981. Since then, numerous experiments studying heterotopic heart transplantation in humans and large animals have confirmed its utility by employing either an intra-abdominal or cervical model. In rats, however, prior research investigating intra-abdominal heterotopic hearts has showed echocardiography to be ineffective. We have recently developed a new technique for heterotopic femoral heart transplantation in rats, which employs the novel use of trans-femoral echocardiography. Therefore, our goal was to re-examine the efficacy of echocardiography for detection of graft rejection.
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Affiliation(s)
- Chad R Gordon
- Division of Surgical Research, Department of Surgery, Robert Wood Johnson Medical School, Cooper University Hospital, Camden, NJ 08103, USA.
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