Merkel Cell Carcinoma Metastases To Caruncle With Orbital Extension: Report and Literature Review

Merkel cell carcinoma (MCC) is an uncommon and aggressive skin cancer of neuroendocrine origin. The tumor usually presents with a locoregional spread and most frequently metastasizes to the skin, liver, bone, lung, and brain. Despite the orbit being a relatively common site of metastases, it has rarely been reported in patients with MCC. The authors present a case of biopsy-proven orbital metastatic MCC in an 86-year-old male who presented with a rapidly enlarging right caruncle/subconjunctival mass with orbital extension and a history of forearm MCC excision 3 years prior. There are only 3 reported cases of distant metastatic MCC to the orbit, all presenting as a mass originating from extraocular muscles; and no cases of caruncle involvement.

Paediatric Orbital Juvenile Xanthogranuloma: A Case Series and Review of the Literature

PURPOSE

Juvenile xanthogranuloma (JXG) is a subtype of histiocytosis characterised histologically by foamy non-Langerhan cells with Touton giant cells. It typically manifests as a single self-limiting cutaneous nodule in the paediatric population. Orbital JXG is extremely rare, and its clinical course and management are not well understood or defined. Herein we present 3 cases of orbital JXG and provide a detailed literature review.

METHODS

Review of 3 cases with orbital JXG and literature review of all published cases.

RESULTS

Three presented cases demonstrate the heterogeneous clinical course of orbital JXG. Although centred around the use of steroids, there is neither robust evidence nor consensus on its management. The wider JXG literature is currently concentrated around the classification of JXG with respect to histiocytosis, especially the exclusion of extracutaneous JXG as separate diseases. This separation is based on clinical, histopathological, and molecular findings. It is unclear where orbital JXG best fits in this emerging classification of JXG.

CONCLUSION

Our review of the cases and literature on orbital JXG show that it may manifest with variable clinical course and its molecular pathogenic mechanism may be different to that of the cutaneous JXG.

Corneal Neurotization for Neurotrophic Keratopathy: A Multicentre Experience

PURPOSE

Corneal neurotization is an emerging technique that offers potential for visual rehabilitation in neurotrophic keratopathy. This study reports on a multicenter experience and outcomes for both direct and indirect methods of corneal neurotization.

METHODS

Retrospective case series. Sixteen patients with neurotrophic keratopathy who underwent corneal neurotization across 5 centers in Australia and Israel were identified for inclusion. Corneal neurotization was performed via direct neurotization from the ipsilateral or contralateral supraorbital/supratrochlear nerve or by the use of an interpositional sural nerve graft. Change in corneal sensitivity (measured in millimeters by the Cochet-Bonnet aesthesiometer), visual acuity, and corneal health.

RESULTS

Over a mean follow-up period of 31.3 months (range: 3 months-8 years), mean corneal sensitivity improved from 3.6 mm (range: 0-25 mm) to 25.3 mm (range: 0-57 mm). Visual acuity improved on average from 20/380 to 20/260. Twelve of 16 patients (75.0%) improved in at least 2 out of the 3 main outcome measures. Nine patients (56.3%) showed an improvement in visual acuity; 13 (81.3%) showed an improvement in average corneal sensitivity; and 11 (68.8%) showed an improvement in corneal health. There were no intraoperative or postoperative complications.

CONCLUSIONS

Corneal neurotization is an emerging surgical treatment option for the management of neurotrophic keratopathy. With appropriate case selection, outcomes are favorable and complication rates are low, for a condition that is otherwise challenging to manage. Patients with severe neurotrophic keratopathy should be considered for this surgical treatment option.

Orbital apex syndrome in herpes zoster ophthalmicus clinical features, treatment and outcomes: a case series and literature review

Orbital Apex Syndrome (OAS) complicating Herpes Zoster Ophthalmicus (HZO) is associated with significant visual impairment. We present four patients with HZO OAS, to highlight clinical features and outcomes in order to promote earlier recognition and management of this potentially sight-threatening complication. CT and MRI imaging findings included expansion and enhancement of extraocular muscles and intraconal fat and involvement of the orbital apex and cavernous sinus. All patients received systemic steroid and antiviral therapy, but a standardised dosage and duration of treatment remains to be defined. Final visual acuity and extraocular motility outcomes were variable.

Isolated Orbital Apex Mucocele: A Case Study and Literature Review

Isolated orbital mucocele without connection between the mass and paranasal sinuses is extremely rare and poorly understood. Literature review of these cases are very few and present more anteriorly in the orbit. Here, the authors present a 33-year-old female with an isolated left orbital apex mucocele without direct communication with the adjacent paranasal sinuses and other vital orbital structures. Endoscopic sinus surgery with marsupialization was performed, and an orbital mucocele was confirmed on histopathology. Although uncommon, previously reported cases, including our patient have remained disease free of recurrence for at least 1 year post-operatively.

Recurrence Following Globe Sparing Excision for Basal Cell Carcinoma with Anterior Orbital Invasion

PURPOSE

Globe-sparing excision for periocular basal cell carcinoma (BCC) with orbital invasion has evident benefits, but the ensuing morbidity and characteristics of recurrence are not well elucidated. This study aims to describe the extent of visual morbidity following globe-sparing excision, and the clinicoradiological characteristics of tumor recurrence.

METHODS

Multicentre retrospective case series.

RESULTS

Eight patients were identified for inclusion in this series. Time to recurrence following globe-sparing excision ranged from 3 to 12 years. Seven patients (87.5%) presented with recurrent disease originating from the medial canthus. Clinical features at presentation included contracture ( n =4, 50.0%), upper lid ptosis ( n =3, 37.5%), a palpable mass ( n =2, 25.0%), and hypoesthesia ( n =2, 25.0%). Radiologically, tumor recurrence was predominantly characterized by isointense signals on T1 and T2-weighted sequences ( n =5, 62.5%) with moderate contrast enhancement. The most common histologic subtype in recurrent tumors was a mixed nodular and infiltrative growth pattern ( n =5, 62.5%). Perineural invasion was a feature in four (50%) cases. Salvage therapy in the form of exenteration was performed in seven cases. Vismodegib and adjuvant radiotherapy were provided for one case with surgically unresectable tumor recurrence.

CONCLUSIONS

Globe-sparing excision for invasive periocular BCC can be complicated by late recurrence that develops rapidly despite silent neuroimaging for years. Early clinical signs are subtle. High-risk features predictive of recurrence include medial canthus location, mixed histological subtypes, and perineural invasion. Patients with such characteristics require lifelong clinical and imaging surveillance following globe-sparing excision.

Aneurysmal Bone Cyst of the Orbit With USP6 Gene Rearrangement

PURPOSE

Aneurysmal bone cyst (ABC) of the orbit is a very rare tumor, occurring mostly in the pediatric population, and can result in sight threatening complications and disfigurement. This review discusses previously reported cases with a focus on evolving treatment options and molecular genetics.

METHODS

We report the youngest case of an orbital ABC with a confirmed gene fusion: a 17-month-old girl, with confirmed FGFR-UPS6 (Fibroblast Growth Factor Receptor 1-ubiquitin specific peptidase 6/tre-2). A literature search for relevant publications on the topic was performed via Medline and PubMed, with the appropriate data extracted.

RESULTS

Thirty-two cases of orbital aneurysmal bone cyst were identified in the literature. Presentations are varied and can include pain, proptosis, decreased vision, and extraocular motility disturbance. Typical imaging and histopathology findings are discussed, in particular the usefulness of identifying USP6 gene arrangements. Treatment modalities are reviewed including surgery, embolization, and receptor activator of nuclear factor kappa-B ligand (RANKL) inhibitors. Recurrences can occur, usually within 2 years.

CONCLUSIONS

Orbital ABC is a neoplasm that presents unique diagnostic and treatment challenges. Gene rearrangements can confirm primary ABC and rule out other underlying pathology. Disfigurement and sight threatening complications can occur due to both the disease process and with treatment. Outcomes may be improved with the use of systemic therapy.

Orbital and Sinonasal Complications of Hydrogel Scleral Buckle: A Case Report

The hydrogel scleral buckle is a hydrophilic implant that is characterized by progressive expansion and can present with secondary orbital changes. The authors present a unique case of hydrogel-induced erosion of the orbital roof into the frontal sinus, with formation of a sino-orbital communication that resulted in frontal sinusitis and adjacent cerebritis. The hydrogel material is radiologically characterized as a fluid-filled hypertense T2 mass with rim enhancement and peripheral calcification. Awareness of late orbital complications from the hydrogel material is important to distinguish this entity from other mimicking orbital pathologies.

Minimally invasive, indirect corneal neurotization using an ipsilateral sural nerve graft for early neurotrophic keratopathy

Purpose

Neurotrophic keratopathy is a degenerative disease characterized by damage to the corneal nerves leading to corneal hypoesthesia and anaesthesia. The resultant progressive visual deterioration is refractory to existing conventional treatment options. Corneal neurotization is a novel and effective surgical procedure that directly targets the underlying pathology of nerve loss by stimulating new corneal nerve growth. This study reports the outcomes and the pre- and postoperative in vivo confocal microscopy findings of the first published Australian case of indirect, minimally invasive, corneal neurotization using an ipsilateral sural nerve autograft.

Observations

An 11-year-old boy developed corneal hypoesthesia in the left eye following surgical debulking of a cerebellopontine angle arachnoid cyst. He was diagnosed with Mackie Stage 1 neurotrophic keratopathy. Due to his hypoesthesia, he had developed recurrent microbial keratitis and corneal ulceration secondary to foreign bodies sustained during contact sports. At presentation, he reported photophobia and dry eye symptoms, corrected-distance visual acuity was 6/18, Cochet-Bonnet aesthesiometer demonstrated reduced corneal sensation (5–15mm), Schirmer's I test was 15mm, and in vivo confocal microscopy showed a complete absence of a subepithelial corneal plexus. He underwent indirect, minimally invasive, corneal neurotization using the ipsilateral supratrochlear nerve and a sural nerve autograft. Subjective improvement in corneal sensation was noticed by the patient at 2 months. Objective improvement, measured on Cochet-Bonnet aesthesiometer, was first observed at 6 months with steady stepwise improvement to 20–35mm at 21 months. Importantly, due to the increase in corneal sensation, the patient did not develop any further corneal complications. At 12 months, dry eye symptoms resolved and Schirmer's I test improved to 30mm. At 15 months, corrected-distance visual acuity improved to 6/5 and in vivo confocal microscopy demonstrated evidence of corneal reinnervation with nerves running through the subepithelial space surrounded by healthy and active keratocytes.

Conclusions and importance

Corneal neurotization represents an exciting development in the armamentarium for the treatment of neurotrophic keratopathy and can be considered for younger patients with early-stage disease.

Yolk sac tumours of the orbit and sinonasal tract

PURPOSE

The aim of this study is to report two cases of paediatric Yolk sac tumours (YST) of the orbit and sinonasal tract, with a major review on the subject.

METHODS

Two case reports along with a comprehensive retrospective literature review of all English language publications between 1974 and 2021 is presented. Literature review examined the demographics, clinical presentation and diagnostic and prognostic factors of extragonadal YSTs of the orbit and sinonasal tract.

RESULTS

Orbit and sinuses are rare sites for YST, with only 25 paediatric cases reported in the literature. Extragonadal yolk sac tumours carry a significantly worse outcome than those localised to the gonads, with the 5-year survival of 66% and 81-89%, respectively. Our review found the median age of presentation to be 18 months (18 months for males and 24 months for females), and females are more commonly affected. The most common presentations were proptosis, facial swelling and ophthalmoplegia. Treatments and therefore outcomes varied in the cases due to the large time period. Of the cases reported in the last 10 years, all patients with data provided were alive and disease-free at follow-up.

CONCLUSION

Sino-orbital yolk sac tumours are rare and have variable presentations, dependent on the extent of local invasion. Early diagnosis and treatment with multimodal therapy are paramount in having improved overall survival.

Pediatric Subcutaneous Panniculitis-like T-cell Lymphoma of the Orbit

Subcutaneous panniculitis-like T-cell lymphoma (SPTCL) is a rare and distinct subtype of peripheral T-cell lymphoma, representing <1% of all non-Hodgkin lymphomas. SPTCL usually arises in the fourth decade of life with multifocal involvement of the limbs and trunk. Orbital disease is uncommon. We present the youngest known case of orbital SPTCL in a 3-year-old child, where the diagnosis was initially confounded by a lower eyelid mass masquerading as preseptal cellulitis. MRI revealed a poorly defined anterior orbital mass. Immunophenotyping and histological analysis of an orbital biopsy specimen confirmed SPTCL, which was managed by the pediatric oncology team with multiagent chemotherapy. This case is unique due to the young age of presentation and primary orbital involvement. Nonresolving or atypical periorbital cellulitis needs to be investigated, as malignancy can mimic such conditions.

Implantation and long-term assessment of the stability and biocompatibility of a novel 98 channel suprachoroidal visual prosthesis in sheep

Severe visual impairment can result from retinal degenerative diseases such as retinitis pigmentosa, which lead to photoreceptor cell death. These pathologies result in extensive neural and glial remodelling, with survival of excitable retinal neurons that can be electrically stimulated to elicit visual percepts and restore a form of useful vision. The Phoenix⁹⁹ Bionic Eye is a fully implantable visual prosthesis, designed to stimulate the retina from the suprachoroidal space. In the current study, nine passive devices were implanted in an ovine model from two days to three months. The impact of the intervention and implant stability were assessed using indirect ophthalmoscopy, infrared imaging, and optical coherence tomography to establish the safety profile of the surgery and the device. The biocompatibility of the device was evaluated using histopathological analysis of the tissue surrounding the electrode array, with a focus on the health of the retinal cells required to convey signals to the brain. Appropriate stability of the electrode array was demonstrated, and histological analysis shows that the fibrotic and inflammatory response to the array was mild. Promising evidence of the safety and potential of the Phoenix⁹⁹ Bionic Eye to restore a sense of vision to the severely visually impaired was obtained.

Corneal neurotisation for neurotrophic keratopathy with a sural nerve autograft: a case report

Neurotrophic keratopathy is a corneal disease characterised by reduced corneal sensation. Corneal neurotization is the transfer of healthy donor nerve tissue to the cornea to restore sensation. An 11-year-old male presented with reduced Mackie Stage 1 neurotrophic keratopathy from de-bulking of a cerebellopontine angle arachnoid cyst. He underwent minimally invasive indirect corneal neurotization with a sural nerve autograft to ipsilateral supratrochlear nerve and cornea. Close and objective post-operative monitoring of donor sites, the cornea, visual acuity, and tear production clearly demonstrate the efficacy of this technique, and the timeline of clinical improvement.

IgG4-related disease of the orbit in an infant

IgG4-related disease is a chronic fibroinflammatory disorder that is becoming increasingly recognized in the pediatric population. The orbit is one of the most commonly affected sites. We present the youngest case of IgG4-related ophthalmic disease in the literature, with an immunodeficiency phenotype associated with a homozygous IRAK-4 variant gene. We also review the clinical and histological features in children with IgG4-related ophthalmic disease. In addition to the young age of presentation, the case is unique for absence of lacrimal gland involvement, dural enhancement on magnetic resonance imaging, and an association with an IRAK-4 deficiency phenotype. Management required a multidisciplinary approach, with judicious use of immunosuppression. IgG4-related ophthalmic disease should be considered as a differential diagnosis in infants and children presenting with an orbital mass. Further, a particularly young age of onset may indicate an overarching immune dysregulation syndrome.

Cavernous sinus embolisation prior to removal of penetrating foreign body in a 6-year-old child

Transorbital penetrating foreign bodies are extremely rare in children and may penetrate the cavernous sinus or the underlying internal carotid artery. Parent vessel sacrifice and temporary balloon occlusion are feasible options for managing arterial injury during removal of the foreign body. Even in the absence of arterial injury, the ophthalmologist may encounter significant bleeding from the cavernous sinus deep in their operative field that is difficult to control. We present a case of a 6-year-old child with a stick penetrating the left superior orbit to enter the cavernous sinus but sparing the internal carotid artery. We describe the first reported experience of prophylactic coil embolisation of the cavernous sinus to minimise intraoperative bleeding during transorbital removal of a foreign body with an excellent clinical outcome.

Panophthalmitis and Orbital Inflammation with Cavernous Sinus Thrombosis Following Cataract Surgery

Background

Panophthalmitis is a severe inflammation of the globe that can result as a rare complication of ophthalmic surgery. In severe cases, it may also be associated with orbital inflammation and cavernous sinus thrombosis.

Purpose

This case demonstrates a rare and life-threatening post-operative complication of cataract surgery. We also hope to highlight the importance of considering the relevant risk factors associated with developing potential infections after cataract surgery, including the use of corneal sutures, high-risk behaviours such as excessive eye-rubbing, and non-compliance with appointments and post-operative medications.

Case Report

We report the case of a 35-year-old female with severe autism and developmental delay who developed panophthalmitis, orbital inflammation and cavernous sinus thrombosis 6 weeks post cataract surgery. The likely cause was corneal suture-related microbial keratitis, and the patient required enucleation due to sepsis.

Conclusion

Post-surgical panophalmitis is a rapidly progressive disease that is not only sight- but life-threatening and demands urgent and intensive treatment. Consideration of early enucleation may be required to prevent deterioration in such patients.

Local delivery of corticosteroids in clinical ophthalmology: A review

Locally administered steroids have a long history in ophthalmology for the treatment of inflammatory conditions. Anterior segment conditions tend to be treated with topical steroids whilst posterior segment conditions generally require periocular, intravitreal or systemic administration for penetration. Over recent decades, the clinical applications of periocular steroid delivery have expanded to a wide range of conditions including macular oedema from retino-vascular conditions. Formulations have been developed with the aim to provide practical, targeted, longer-term and more efficacious therapy whilst minimizing side effects. Herein, we provide a comprehensive overview of the types of periocular steroid delivery, their clinical applications in ophthalmology and their side effects.

Intranasal corticosteroids do not affect intraocular pressure or lens opacity: a systematic review of controlled trials

BACKGROUND

Intranasal corticosteroids (INCS) are prescribed for the long-term prophylactic treatment of inflammatory upper airway conditions. Although some systemic absorption can occur via topical routes, the clinical relevance is controversial. The effects of orally administered corticosteroids on intraocular pressure (IOP) and lens opacity (LO) are well established, but the impact of the INCS is less well defined. This study aims to systematically review the literature for evidence of adverse occular events with INCS use.

METHODOLOGY

A systematic review of literature from Medline and Embase databases (January 1974 to 21st of November 2013) was performed. Using the PRISMA guidelines, all controlled clinical trials of patients using INCS, that reported original measures of IOP, LO, glaucoma or cataract incidences were included. Studies with adjuvant administration of oral, inhaled and intravenous steroids were excluded.

RESULTS

665 articles were retrieved with 137 were considered for full-text review. Of these, 116 (85%) were literature reviews and two were case reports. 19 studies (10 RCTs, 1 case-control, 8 case series) were included for the qualitative review, of which 18 reported data on IOP and 10 on cataract/LO. None (n=0) of the 10 RCT reporting data on glaucoma or IOP demonstrated changes in IOP compared to control. Also none (n=0) of the 6 RCTs reporting cataract or lens opacity demonstrated changes compared to control.

CONCLUSION

Data from studies with low levels of bias, do not demonstrate a clinically relevant impact of INCS on neither ocular pressure, glaucoma, lens opacity nor cataract formation.

Systematic review and meta-analysis on outcomes for endoscopic versus external dacryocystorhinostomy

BACKGROUND

Dacryocystorhinostomy (DCR) is commonly performed for epiphora, dacryocystitis and during tumor surgery. External (EXT-DCR) and endoscopic DCR (END-DCR) are both practiced. END-DCR was initially performed with laser (EL-DCR) but has shifted to careful bone removal with mechanical drills (EM-DCR). High level evidence from comparative cohorts was sought to compare outcomes.

METHOD

Medline (1966 - January 28th, 2013) and Embase (1980 - January 28(th), 2013) were searched for comparative studies (RCT/cohorts) of END-DCR to EXT-DCR for acquired nasolacrimal duct (NLD) obstruction. Primary outcome was DCR success, defined as resolution of symptoms and/or patent NLD on irrigation or dacroscintography. Secondary outcomes were scarring, infection and post-operative bleeding. Meta-analysis was performed with the Mantel-Haenszel Method and presented as Risk Ratios (RR) with Confidence Intervals (CI).

RESULTS

The search identified 3582 studies and 355 were reviewed after screening. Full text review yielded 19 studies (4 RCTs and 15 cohorts). Overall, EXT-DCR had slightly better success rates than END-DCR (RR 0.96, CI 0.93-1.00). However, EM-DCR outcomes were comparable to EXT-DCR (RR 1.02, CI 0.98-1.06), whereas EL-DCR had poorer outcomes (RR 0.85, CI 0.79-0.91) when compared separately. The RR for scarring, bleeding and infection with END-DCR versus EXT-DCR was 0.07 (CI 0.02-0.22), 0.72 (CI 0.46-1.13) and 0.24 (CI 0.11- 0.54), respectively. The rates of reported revision surgery were similar.

CONCLUSION

DCR is a procedure with high success rates. Endoscopic procedures differ greatly by technique with EM-DCR offering comparable results to EXT-DCR, without the risk of cosmetically unacceptable scars.

The use of a pleated strip of autogenous temporalis fascia graft for frontalis suspension in recurrent poor levator function ptosis in adult patients

PURPOSE

Poor levator function (LF) blepharoptosis can be corrected surgically using frontalis muscle suspension with a variety of materials. Autogenous grafts such as fascia lata are commonly used. The need for a remote surgical site and the risk of an unattractive leg scar makes the use of an autogenous temporalis fascia (ATF) graft appealing as the scar is concealed in the hair. We describe the use of a pleated, lengthened ATF graft that is easy to prepare and insert, and provides a cosmetically acceptable outcome.

METHODS

Prospective case series describing six patients with previous multiple failed lid surgeries and recurrent poor (≤ 5 mm) LF (mean 2.87 ± 1.72 mm) ptosis. The pleated graft technique was used to yield a strip of ATF up to 18-cm long from a short 2-cm temporal incision. Eight eyelids then underwent ATF graft frontalis suspension surgery using the modified Fox pentagon technique. Outcomes included eyelid measurements with 4.5-year follow-up.

RESULTS

All patients achieved good functional and esthetic outcome. The mean central palpebral aperture 6 weeks postsurgery was 7.14 ± 1.67 mm, equating to a mean increase of 3.27 mm (p < 0.05 using the paired t-test). The improvement in eyelid height was maintained at the 4.5-year follow-up in all patients, except one who died of unrelated cause.

CONCLUSION

A pleated strip of ATF graft provides a simpler alternative to fascia lata grafting for frontalis suspension in poor LF ptosis in adult patients with good long-term results.

Mucinous sweat gland adenocarcinoma of the eyelid - current knowledge of a rare tumor

PURPOSE

To review the medical literature on mucinous sweat gland adenocarcinoma of the eyelid (MSA) and present two new cases.

METHODS

Details of published case reports and small series (between 1971-2010) were evaluated and summarized including two patients diagnosed and treated at our institution. Data regarding age, gender, ethnicity, precise location, clinical presentation, treatment and follow up of each patient were collected.

RESULTS

25 reports describing 55 patients were found in the medical literature. The mean age was 61.3 years (30-87), 22(59%) were male and 28(80%) were Caucasian. In 23(44.2%) patients the lesion was in the lower lid, in 20(38.5%) in the upper lid, in 3(5.7%) involving both lids and in 6(11.6%) in a canthus. In 12(21.8%) patients a lesion with a benign diagnosis was previously excised from the same location. In 2 of them histological re-examination resulted in a diagnosis of MSA. Intraorbital involvement was found in 2(3.6%) patients. Regional lymph node metastasis was found in 2(4.4%) patients. Surgical excision was the treatment of choice using Mohs' micrographic-controlled excision technique in recent years. Radiotherapy was applied to 2 patients with clinical resolution in 1. Recurrence of the tumor was reported in 14(30%) patients.

CONCLUSIONS

MSA is a rare tumor of the eyelid with no clinically distinguishing features. It should be suspected particularly with recurrent eyelid lesions and must be differentiated from metastatic disease. The tumor may extend into the orbit and metastasize regionally. Surgical removal with continued regular follow-up examination is the treatment of choice.

Primary orbital liposarcoma

PURPOSE

To describe 6 new cases of primary orbital liposarcoma and provide a review of the relevant literature.

DESIGN

Noncomparative consecutive case series and literature review.

PARTICIPANTS

Six patients with primary orbital liposarcoma.

METHODS

Review of patient charts, imaging, and histopathology; literature review.

MAIN OUTCOME MEASURES

Patient demographics; clinical presentations; results of radiologic imaging; histopathology; surgical techniques used and their complications; other treatment modalities; outcomes and recurrences.

RESULTS

Six cases of primary orbital liposarcoma were identified, 5 of which were primary presentations and 1 of which was a recurrence. In 4 cases, exenteration was deferred, resulting in recurrence of disease in all 4. All cases were exenterated, and 2 cases had local recurrence despite exenteration. Two cases were associated with the Li-Fraumeni syndrome and other malignancies. Literature review identified 34 other cases of primary orbital liposarcoma, which, partly because of its rarity, is frequently initially misdiagnosed. The most common subtype is myxoid (56.8%); other types are pleomorphic (10.8%) and well differentiated (29.7%). Well-differentiated tumors have the best prognosis. Non-exenterating surgery was associated with recurrence, although recurrence post-exenteration also occurred. Although radiotherapy has an established role in the treatment of nonorbital liposarcoma, the role of both radiotherapy and chemotherapy in the management of primary orbital liposarcoma is still unclear.

CONCLUSIONS

Orbital liposarcoma remains a diagnostic and surgical challenge. Exenteration remains the treatment of choice, but clinicians must also be aware that liposarcoma may herald the diagnosis of the Li-Fraumeni familial cancer syndrome.

Linear scleroderma as a rare cause of enophthalmos: a case report

INTRODUCTION

Enophthalmos is an important physical sign which can be easily missed.

CASE PRESENTATION

A 64-year old female presented with painless and progressive shrinking of her right eye. Visual acuity was 6/6 in both eyes. The main clinical findings included exophthalmometry readings of 14 mm in the right eye and 22 mm in the left eye and a linear scar on her right forehead. This scar is a feature of linear scleroderma and called "en coup de sabre". She was referred to a dermatologist for further assessment.

CONCLUSION

Enophthalmos is defined as the relative recession of the globe into the bony orbit and if measuring greater than 2 mm can give a noticeable cosmetic deformity. Scleroderma is a systemic or localised disease. Linear scleroderma has the following features-localised fibrosis of the skin, blood vessels, subcutaneous fat, muscle and sometimes bone. Histology shows an inflammatory and a sclerotic phase. Ophthalmic effects include enophthalmos, lash loss, lid induration or tightening and periorbital oedema.

Esophageal adenocarcinoma metastatic to the orbit

A 75-year-old woman presented with orbital and ethmoidal metastases from an esophageal adenocarcinoma 6 months after diagnosis of the primary.

Primary Orbital Ewing Sarcoma in a Middle-Aged Man

A 54-year-old man presented with a painful left proptosis and a soft tissue mass at the inferolateral aspect of the left orbit with bone involvement. There was no clinical or investigational evidence of systemic disease. Both light microscopy and immunohistochemistry were required for the diagnosis of Ewing sarcoma. After failure of chemotherapy alone, management included extensive surgical excision and postoperative adjuvant radiotherapy and chemotherapy. Despite intervention, the patient died of widespread metastatic disease 17 months after initial presentation. Although rare, Ewing sarcoma should be included in the differential diagnosis of uniform round cell orbital tumors in adults.

Conjunctival squamous cell carcinoma: atypical presentation of HIV

Metastatic squamous cell carcinoma (SCC) of the conjunctiva is uncommon in Western countries. A Nigerian patient who presented with right lower lid swelling treated as a chalazion is described here. She re-presented 5 months later with widespread metastatic conjunctival SCC and positive HIV serology. Conjunctival SCC may be difficult to distinguish on clinical appearance alone and in an era of increasing global travel, young patients with a history of high ultraviolet-B radiation exposure and from countries with a high HIV prevalence should be given a low threshold for excision biopsy.

Bilateral Leukemic Orbital Infiltration Presenting as Proptosis and Narrow-Angle Glaucoma

A 71-year-old man with acute myeloid leukemia presented with bilateral uveal and orbital leukemic infiltration presenting as tense bilateral proptosis, orbital inflammation, and acute-angle closure glaucoma. B-scan ultrasonography revealed uveoscleral thickening and anterior rotation of the ciliary body. Orbital CT and MRI showed bilateral proptosis with streaking of intraconal fat. Temporary pressure lowering occurred after lateral canthotomy and inferior cantholysis. Definitive treatment included systemic chemotherapy and steroids. Over a 2-week period, vision improved and proptosis resolved, and the intraocular pressure returned to normal. The patient died of cerebral complications of his illness after 6 weeks. This is the first reported case of orbital and ocular leukemic infiltration presenting simultaneously as tense proptosis and narrow-angle glaucoma.

Cardiovascular disease, vascular risk factors and the incidence of cataract and cataract surgery: the Blue Mountains Eye Study

PURPOSE

To assess whether an association exists between cardiovascular disease, vascular risk factors and incident cataract and cataract surgery.

METHODS

The Blue Mountains Eye Study examined 3654 participants > or = 49 years of age during 1992-4, then 2335 survivors (75.1%) after five years. Trained interviewers administered a vascular history questionnaire; height, weight and blood pressure were measured. Lens photographs from both examinations were graded for presence of cortical, nuclear or posterior subcapsular cataract.

RESULTS

Obesity (body mass index > or = 30 kg/m2) was significantly associated with increased incidence of both cortical [odds ratio (OR) 1.6, 95% confidence interval (CI) 1.2-2.2] and posterior subcapsular cataract (OR 2.1, CI 1.2-3.7). Hypertensive participants using medication and aged less than 65 years at baseline had a higher incidence of posterior subcapsular cataract (OR 3.4, 95% CI 1.3-8.4) than normotensive subjects. A history of angina was associated with higher cataract surgery incidence (OR 2.1, 95% CI 1.3-3-5).

CONCLUSIONS

These longitudinal data provide some evidence supporting a relationship between cardiovascular disease, vascular risk factors and incident cataract and cataract surgery. The findings confirm a number of associations previously documented in cross-sectional data.

Five year incidence of cataract surgery: the Blue Mountains Eye Study

AIMS

To assess the 5 year incidence of cataract surgery in an older population based prospective cohort.

METHODS

5 Year prospective follow up of the population based Blue Mountains Eye Study (BMES) performed in 1992. The follow up study examined 2335 survivors (75.1%) of the 3654 baseline participants. Baseline and 5 year slit lamp and retroillumination lens photographs were graded for presence of cortical, nuclear, or posterior subcapsular cataract using the Wisconsin cataract grading method and cataract surgery was documented from the history and the clinical examination.

RESULTS

An overall cataract surgery rate of 5.7% in first or both eyes was documented. The incidence was 0.3% in people aged 49-54 years at baseline, 1.7% for ages 55-64 years, 7.9% for ages 65 to 74 years, and 17.4% in people aged 75 years or older. The rate of surgery in first or both eyes was 6.0% in women and 5.2% in men, age adjusted p = 0.66. Bilateral cataract surgery was performed during follow up on 2.7% of participants, while 43.1% of unilateral phakic cases had second eye surgery. Presence of any posterior subcapsular (PSC) cataract, either alone or in combination with other cataract types, was the most likely type of cataract at baseline to be associated with incident cataract surgery. Baseline age was the most important non-ocular variable predicting incident cataract surgery.

CONCLUSIONS

This study has documented age specific rates for 5 year incident cataract surgery in an older community. The finding of relatively similar incidence rates and ocular predictors of cataract surgery to those reported by the Beaver Dam Eye Study, Wisconsin, United States, is of interest, given previous documented similarities between these two populations.