Bilateral, sequential orbital inflammatory syndrome associated with ruxolitinib

Ruxolitinib is an oral Janus associated kinase (JAK) inhibitor commonly used in the treatment of primary myelofibrosis. We describe a case of an 86-year-old woman on ruxolitinib for primary myelofibrosis who presented with a three-day history of worsening left eyelid swelling, pain, and decreased vision. Her exam was notable for left upper lid ptosis, periorbital edema, and nearly complete external ophthalmoplegia along with diffuse conjunctival injection and microcystic corneal edema. An orbital computed tomography demonstrated left proptosis accompanied by extensive inflammatory changes of the preseptal and orbital soft tissues. She was diagnosed with acute left orbital inflammatory syndrome (OIS) and treated with intravenous methylprednisolone, one gram over 48 hours followed by an oral steroid taper as well as discontinuation of her ruxolitinib. Complete recovery was noted at her one-week follow-up visit and ruxolitinib was restarted. However, 3 weeks later, she presented with new right periorbital swelling and pain and was found to have a sequential right OIS for which she was again treated with methylprednisolone and discontinuation of ruxolitinib with the goal of transitioning to an alternative biologic agent. Although there are no previous documented cases of ruxolitinib associated orbital inflammatory syndrome, a similar JAK inhibitor medication, Fedratinib, has been reported to cause a similar side effect. We propose that her ruxolitinib paradoxically lead to a pro-inflammatory state leading to bilateral, sequential orbital inflammatory syndrome.

Spontaneous Subperiosteal Orbital Hematoma Associated With Cocaine-Induced Midline Destructive Lesion

The authors present a case of a non-traumatic, spontaneous subperiosteal orbital hematoma in a woman with a history of chronic pansinusitis and absence of midline nasal cavity structures due to chronic inhalational cocaine use. The patient underwent left orbitotomy and drainage of the lesion, showing mostly blood with a small amount of purulence that grew methicillin-resistant Staphylococcus aureus when cultured. The patient received 4 weeks of intravenous antibiotics in addition to functional endoscopic sinus surgery. At 1 month after surgery, her vision had returned to baseline, and proptosis was resolved. Fewer than 20 cases of subperiosteal orbital hematomas associated with chronic sinusitis have been reported. To the authors' knowledge, this is the first reported case of a subperiosteal orbital hematoma associated with cocaine-induced midline destructive lesions. Patient consent to obtain photographs was obtained and archived. All collection and evaluation of patient health information were compliant with the Health Insurance Portability and Accountability Act, and this report adheres to the Declaration of Helsinki.

Proposal of a simple grading system integrating cosmetic and tonometric aspects of prostaglandin-associated periorbitopathy

The distribution of prostaglandin-associated periorbitopathy (PAP) graded using the Shimane University PAP Grading System (SU-PAP) among glaucoma/ocular hypertension subjects using a topical FP or EP2 receptor agonist was reported. A 460 consecutive 460 Japanese subjects (211 men, 249 women; mean age ± standard deviation, 69.9 ± 14.5 years) who had used either a FP agonist (0.005% latanoprost, 0.0015% tafluprost, 0.004% travoprost, 0.03% bimatoprost, or fixed combinations of these) or EP2-agonist (0.002% omidenepag isopropyl) for more than 3 months in at least 1 eye were retrospectively enrolled. Age, sex, prostaglandin, intraocular pressure (IOP) measured by Goldmann applanation tonometry (IOPGAT) and iCare rebound tonometry (IOPRBT), difference between IOPGAT and IOPRBT (IOPGAT-RBT), PAP grade, and PAP grading items were compared among groups stratified by PAP grade or prostaglandins. Of the study patients, 114 (25%) had grade 0 (no PAP), 174 (38%) grade 1 (superficial cosmetic PAP), 141 (31%) grade 2 (deep cosmetic PAP), and 31 (7%) grade 3 (tonometric PAP). The IOPGAT was significantly higher in grade 3 (17.5 ± 5.4 mm Hg) than grades 0 (15.0 ± 5.1 mm Hg, P = .032) and 1 (14.5 ± 4.2 mm Hg, P = .008), and the IOPGAT-RBT was significantly higher in grade 3 (5.8 ± 3.2 mm Hg) than the other 3 grades (1.3-1.9 mm Hg, P < .001 for all comparisons); the IOPRBT was equivalent among the 4 grades. The PAP grade was significantly higher associated with travoprost (2.0 ± 0.8) and bimatoprost (2.0 ± 0.7) than latanoprost (1.0 ± 0.8, P < .001 for both comparisons) and tafluprost (1.0 ± 0.7, P < .001 for both comparisons), but significantly lower associated with omidenepag (0.0 ± 0.0, P < .001 for all comparisons) than the other 4 prostaglandins. Multivariate analyses showed older age (standard β = 0.11), travoprost (0.53, referenced by latanoprost) and bimatoprost (0.65) were associated with higher PAP grades, while tafluprost (-0.18) and omidenepag (-0.73) were associated with lower PAP grades. The PAP graded using SU-PAP reflects the degree of overestimation of the IOPGAT and different severities of PAP among the different prostaglandins. SU-PAP, the grade system constructed based on the underlining mechanisms of PAP, is a simple grading system for PAP that is feasible for use in a real-world clinical situation.

Shortening of Interpupillary Distance after Instillation of Topical Prostaglandin Analog Eye Drops

PURPOSE

To investigate changes in the interpupillary distance (IPD) after continual instillation of topical prostaglandin analogs (PGAs) in glaucoma patients as an objective indicator of prostaglandin-associated periorbitopathy (PAP).

DESIGN

Retrospective, comparative case series.

METHODS

A total of 152 institutional patients with glaucoma were enrolled in this study. Inclusion criteria were visual acuities exceeding 10/20 bilaterally and no intraocular surgery during observation. Intervention/observation procedures: First-time bilateral instillation of bimatoprost, travoprost, latanoprost, or tafluprost and IPDs measured by automatic refractometry. IPDs, intraocular pressures (IOPs), and refractive errors were measured before and after continual drug administration (treatment, 2-24 months).

MAIN OUTCOME MEASUREMENTS

Post-treatment changes in IPDs. A total of 61 untreated patients served as controls.

RESULTS

The IPDs shortened significantly (P < 0.001) after treatment (-0.80 ± 2.1 mm); the IPDs of control subjects remained unchanged (0.05 ± 0.96 mm; P = 0.69). The IPD change after bimatoprost instillation (-2.20 ± 0.97 mm) was significantly (P < 0.001) greater than with other PGAs (-0.65 ± 2.09 mm). The IOPs decreased significantly (P < 0.001) (-3.7 ± 4.3 mm Hg); the refractive errors did not change significantly (P < 0.099) (-0.07 ± 0.69 diopter) post-treatment. The percentages of subjects with 2-mm or greater decreases in IPD after bimatoprost, travoprost, latanoprost, or tafluprost were 85.7%, 20.0%, 18.2%, and 17.2%, respectively, and with 3-mm or greater decreases in IPD 35.7%, 12.0%, 14.5%, and 12.1%, respectively. The specificities were 93.4% and 100% in the control group, respectively, with IPD threshold changes of 2 and 3 mm or more, respectively.

CONCLUSIONS

The IPD decreased significantly after topical PGAs within 24 months. The effect was significantly greater with bimatoprost than with other PGAs. The noninvasive, immediate automatic refractometry measurement may be an objective numerical indicator of PAP.

Bisphosphonate-induced orbital inflammation: more common than once thought?

To report two cases of bisphosphonate-induced orbital inflammation, discuss the clinic-radiological features and management options, and highlight the increasing frequency of an association previously considered extremely rare. A retrospective review of two cases presenting to our department, and review of the literature reporting this association. Two new cases of bisphosphonate-induced orbital inflammation were added to the literature. The first occurred in the context of a risedronate re-challenge, and the second with zoledronic acid. Both cases were managed successfully with topical steroids. Clinicians prescribing bisphosphonates, particularly for the first time, should be aware of the increasingly reported association with orbital inflammation. The presence of suggestive clinical features should prompt urgent referral to an ophthalmologist for appropriate management.

Long-term adverse event: inflammatory orbitopathy induced by pembrolizumab in a patient with metastatic melanoma

The recent advent of immune checkpoint inhibitors (ICI), including anti-programmed cell death 1 protein (anti-PD-1) agents has revolutionized the therapeutic approach of metastatic malignancies. Yet, ICI can disrupt immune tolerance resulting in enhanced immune activation in normal tissues with significant toxicity. A dysregulated activation of T-cells directed to normal tissues stands as the main mechanism of immune-related adverse events (irAE). To date, only two cases of immune-related inflammatory orbitopathy related to anti-PD-1 agents have been reported. This rare immune adverse event usually occurred early after ICI initiation. Here, we report the first case of late inflammatory orbitopathy occurring in a melanoma patient treated with pembrolizumab. Consequently, the occurrence of irAE under ICI should be monitored, even late after treatment instauration.

Inflammatory Orbitopathy Associated With Ipilimumab

In this case report, the clinical presentation of an inflammatory orbitopathy seen following treatment with ipilimumab is described. After 3 rounds of ipilimumab (10 mg/kg) treatment for Stage III metastatic melanoma, the subject of this case report developed acute eye pain and proptosis. At initial presentation, she had marked proptosis and diffuse severe ophthalmoparesis. After treatment with high-dose steroids, over a period of 6 months, the symptoms gradually resolved fully. Although the condition may mimic thyroid-associated orbitopathy, imaging and laboratory features suggest that the orbitopathy associated with ipilimumab is not a secondary effect of thyroid dysfunction but a distinct inflammatory condition. The authors conclude that immune-related side effects can occur with biologic agents used to treat malignancies and these side-effects can involve the eye. This case illustrates the occurrence of an inflammatory orbitopathy associated with ipilimumab treatment.

Factors Related to Prostaglandin-Associated Periorbitopathy in Glaucoma Patients

PURPOSE

To determine factors related to prostaglandin-associated periorbitopathy (PAP) and its prevalence in glaucoma or ocular hypertension (OHT) patients using prostaglandins analogs (PGAs).

DESIGN

A cross-sectional study.

METHODS

A study of glaucoma or OHT patients, using topical PGAs for at least 3 months, was performed. Eyes treated with PGAs were photoraphed and independently evaluated for PAP by 2 glaucoma specialists using at least 4 out of 7 clinical appearances. The factors of interest were sex, age, body mass index (BMI), types of glaucoma, types of PGAs, duration of PGA use, and concurrent 0.5% timolol. Univariate (χ2 test) and multivariate (multiple logistic regression) analyses assessing risk factors for PAP were performed to estimate the odds ratios (OR) with 95% conidence intervals (CIs).

RESULTS

One hundred thirty-four eyes from 134 patients were included. Seventy (52.2%), 21 (15.7%), and 43 (32%) eyes received components of latanoprost, travoprost, and bimatoprost, respectively. Prevalence of PAP was 44.8% (95% CI, 36.3 to 53.3). Older age >60 years (OR, 3.0; 95% CI, 1.2 to 7.8), bimatoprost (OR, 4.0; 95% CI, 1.6 to 9.5), travoprost (OR, 3.3; 95% CI, 1.1 to 10.1), and timolol (OR, 2.9; 95% CI, 1.3 to 6.8) were at risk of PAP development. In addition, BMI ≥23 kg/㎡ (OR, 0.3; 95% CI, 0.1 to 0.7) was reversely associated with PAP.

CONCLUSIONS

Older age, bimatoprost, or travoprost were associated with PAP, whereas high BMI was found as a protective factor. Interestingly, timolol possibly precipitated periorbital change when in use with prostaglandins.

Skin lesions in patients treated with imatinib mesylate: a 5-year prospective study

Imatinib mesylate (IM) represents the first-line treatment of patients with chronic myeloid leukemia (CLM) or gastrointestinal stromal tumor (GIST). It presents several side effects. However, less than 10% are nonhematologic including nausea, vomiting, diarrhea, muscle cramps, and cutaneous reactions. The aim of our study was to identify data regarding IM cutaneous adverse effects (AEs) to improve the clinical diagnosis and management of the more frequent side effects. Skin examination should be done before and during IM treatment so that AEs can be diagnosed and treated early with less impact on chemotherapy treatments and on the quality of life of the patient.

Localized Periorbital Edema Induced by Ibuprofen

We documented localized periorbital edema in one patient with ibuprofen sensitivity without underlying chronic urticaria. The reaction developed one hour after ingestion of 200 mg of ibuprofen. No systemic symptoms were observed. No other NSAIDs did not induce symptoms. This patient was able to tolerate doses of ibuprofen after pretreatment with terfenadine. These observations suggest that histamine played a central role in this ibuprofen-induced skin reaction. Treatment with terfenadine enabled the patient to tolerate ibuprofen without experiencing any side effects. To the best of our knowledge, this is the first reported case of periorbital edema induced by ibuprofen.

[Peri-orbital oedema and therapy-resistant hypertension: unusual side-effects of clozapine]

A 49-year-old male, known to have been suffering from paranoid schizophrenia for 10 years, was treated twice with clozapine. Although the clozapine alleviated his psychosis, the patient developed peri-orbital oedema repeatedly. As a result he requested a switch to a different antipsychotic. Also, while the patient was on clozapine, it proved difficult to regulate his hypertension. A possible explanation for these two side-effects is that clozapine blocks the renal dopamine D4 receptor, preventing it from performing its normal natriuretic and diuretic function. In view of the high but largely unnoticed incidence of hypertension in patients on clozapine (4%), we advise that such patients should receive structured somatic screening in a clinical setting.

Two cases of drug-induced orbital inflammatory disease

Orbital inflammatory disease (OID) includes all inflammatory processes affecting the orbit. Although several aetiologies are recognised, a cause may not be elucidated. We describe 2 cases in which drugs (hyaluronidase and zoledronic acid) were the cause of OID. In patients with a clinical picture of OID simulating an orbital cellulitis, the recent drug history should be considered as a possible aetiology, and treatment with steroids with or without a biopsy should be considered after an infection has been excluded.

Zolendronate associated inflammatory orbital disease

Bisphosphonate infusions are associated with adverse events in approximately a third of patients. Ocular complications are rare and even more so, inflammatory orbital disease. Bisphosphonate-induced orbital inflammation is not a well recognised complication and there have been only a few published case reports of this. We present a case of orbital inflammatory disease associated with zolendronate infusion.

Periorbital contact sensitization

PURPOSE

To identify frequency and pattern of contact sensitization among patients with periorbital dermatitis.

DESIGN

Cross-sectional retrospective investigation of 1247 patients referred for patch testing over a 17-year period.

METHODS

Data were collected for patients undergoing patch testing to the standard and customized trays between January 1990 and December 2006 at the Massachusetts General Hospital, Contact Dermatitis Clinic. Our study group consisted of 266 patients affected by periorbital dermatitis. Findings were compared to 981 referrals without periorbital dermatitis (controls). Patch test results were read after 48 and 72 hours and classified as allergic, questionable, irritant, or negative. Statistical analyses were carried out by using chi(2) test and Fisher exact test.

RESULTS

General epidemiologic data among periorbital dermatitis patients showed significant predominance of female gender (87.6%) and of individuals aged 40 to 59 years (45.9%). Nickel (16.5%) and fragrance mix (13.2%) were the top-ranking sensitizers. Ingredients of topical ophthalmologic products did not result in significant sensitization. Comparison of the periorbital dermatitis group to the controls did not reveal significant differences in sensitization pattern. Patch testing confirmed the likelihood of allergic contact dermatitis in 50.8% of the periorbital dermatitis patients tested.

CONCLUSIONS

Allergic contact dermatitis is a common cause of periorbital dermatitis. Patch testing should be considered in all patients with periorbital dermatitis when suspecting contact allergy in order to identify and avoid offending allergens.

Orbital inflammatory disease secondary to a single-dose administration of zoledronic acid for treatment of postmenopausal osteoporosis

A 60-year-old woman received a single 5-mg dose of zoledronic acid (Aclasta) for treatment of postmenopausal osteoporosis. One day after receiving the drug, she acutely developed a painful periorbital swelling, chemosis, and hyperemia in the right eye. The condition worsened despite initial treatment with topical steroids. An orbital CT scan showed right eye proptosis, eyelid edema, and intraorbital fat stranding. A diagnosis of orbital inflammatory disease was made, and the patient was treated with high-dose oral steroids (prednisone 80 mg/day) tapered along 6 weeks. The symptoms and the swelling reduced progressively after initiating oral prednisone, and after 12 days, there was complete resolution of the condition. The patient remained symptom free and had no remission after the treatment interruption.

[Orbital emphysema due to perfluoropropane gas anesthesia in retinal surgery. A case report]

A 45 year old male was referred by the increasing volume of upper and lower eyelids with lost vision of his right eye after surgical procedure for recurrent retinal detachment. The surgery performed was a scleral buckle, vitrectomy and application of perfluoropropane gas to right eye. Ophthalmic examination: visual acuity of the right eye showed counting fingers 2 meters, soft tissue crepitating and proptosis. Anterior subconjuntival segment was infiltrated by gas, with normal intraocular pressure. CT scan shows gas in soft tissues. Because we did not find change in the intraocular pressure or damage to the optic nerve we did not propose surgical treatment. We managed conservatively considering that this gas tends to reabsorp totally as it occurred.

Orbital inflammation after use of zoledronic acid for metastasized prostate carcinoma

Report of a case of orbital inflammation after the use of zoledronic acid for metastasized prostate cancer.

Trabeculectomy trapdoor separation with allergic periorbital dermatitis: an unusual late-onset complication of guarded filtration surgery

Hypotony post trabeculectomy may be the result of excessive aqueous outflow. Herein a case of an elderly man with excessive filtration 2 years post trabeculectomy resulting from trapdoor separation associated with allergic periorbital dermatitis is presented. Quaternary ammonium compounds are a significant cause of allergic periorbital dermatitis. Chronic rubbing associated with allergies to multiple topical quaternary ammonium compound-containing ophthalmic preparations is likely to have contributed to the trapdoor autotrauma and separation in this man with a background of allergic contact dermatitis.

[Invasive aspergillosis of the skull base with orbit infiltration]

BACKGROUND

[corrected] Aspergillosis of the paranasal sinuses is subdivided into noninvasive and invasive types, depending on invasion of the tissue. The invasive form often occurs in immunodeficient patients and can be divided further into granulomatous, chronic invasive, and acute fulminating forms.

CASE REPORT

We report the clinical course of an immunosuppressed 64-year-old male with invasive aspergillosis originating from the sphenoid sinus with infiltration of the orbit and intracranial extension into the cavernous sinus. The patient was referred to our hospital with loss of vision, ptosis, and ophthalmoplegia of 3-month duration. Additionally he suffered from diabetes mellitus II and kidney failure after kidney transplantation. After CT scanning, endonasal sinus debridement and decompression of the orbit were carried out immediately. Histology revealed invasive aspergillosis. Postoperatively, both systemic and local antimycotic therapy and antibiotic treatment were performed. According to recommendations of the Undersea and Hyperbaric Medicine Society, cerebral abscess is a certain indication of hyperbaric oxygenation. We decided to attempt therapy for that as well. The patient died 3 weeks after surgical intervention due to carotid dissection.

CONCLUSION

Invasive aspergillosis of the paranasal sinuses and the skull base of immunsuppressed patients is usually lethal because of intracranial complications. Therefore, fast diagnosis using CT and MRI and surgical and antimycotic therapy are necessary.

Bilateral periorbital necrotizing fasciitis following exposure to Holi colors: a case report

Holi festival is celebrated in India traditionally by applying colors on one another. Various ocular adverse effects of these colors have been reported including conjunctivitis and corneal abrasion. We report a case of bilateral periorbital necrotizing fasciitis, following exposure to Holi colors. General physicians might encounter more such cases after exposure to Holi colors. In India, these colors are prepared on a small scale and lack any quality checks. Use of such toxic colors should be discouraged, and all doctors should caution people against using synthetic dyes. This case report highlights the need to put manufacturing of Holi colors under guidelines of the Food and Drug Cosmetic Act and the Bureau of Indian Standards.

Isolated Periorbital Angio-Oedema Induced by Aspirin: A Case Report and Review of the Literature

Periorbital angio-oedema may present as an isolated manifestation of aspirin intolerance and can be very alarming to the patient. This case describes a 38-year-old gentleman with such localized clinical features. Once considered an unusual phenomenon, review of the literature has revealed an increased frequency, possibly as a result of previous poor documentation. Clinical manifestations of nonsteroidal anti-inflammatory drugs (NSAIDs) intolerance, in particular periorbital angio-oedema and its associated symptoms, with proposed aetiology and pathogenesis, are discussed.

CLINICAL RELEVANCE

With the wide use of this drug and other NSAIDs for the relief of painful and inflammatory dental and facial conditions, such localized manifestation of aspirin intolerance may present to the general dental practitioner and other dental specialties. Patients' medical history may reveal sensitivity to these groups of drugs, and in such cases, should be avoided and suitable alternatives provided.

Intraorbital Heroin Injection Resulting in Orbital Cellulitis and Superior Ophthalmic Vein Thrombosis

A 47-year-old man with decreased vision, ophthalmoplegia, proptosis, and chemosis of his right eye admitted to injecting heroin directly into his orbit. He was placed on intravenous antibiotics for orbital cellulitis, and computed tomography and magnetic resonance imaging were performed. Superior ophthalmic vein thrombosis (SOVT) was noted on magnetic resonance imaging. The patient responded well to intravenous antibiotics, and his symptoms resolved with minimal deficits. Steroids and anticoagulants were not administered. We review the pathogenesis of septic SOVT and briefly discuss the role of anticoagulants and steroids in this setting.

Allergic reaction to hyaluronidase: a rare cause of orbital inflammation after cataract surgery

PURPOSE

The aim of this study was to present a series of patients with acute orbital inflammatory symptoms secondary to peribulbar hyaluronidase allergy and to discuss the diagnostic and management modalities.

METHODS

Review of clinical records of all patients with acute orbital inflammatory symptoms after uneventful cataract surgery, seen at two ophthalmology departments. The main outcome measures included clinical signs and symptoms, imaging findings, post-operative course, skin allergy testing, and final outcome.

RESULTS

There were five patients (four women, one man) with a mean age of 78+/-7.0 years. Signs and symptoms appeared 12-72 h after cataract surgery and included axial proptosis, periorbital erythema with swelling, and extraocular muscle (EOM) function restriction (5/5), periorbital pain or itchiness (3/5), and conjunctival chemosis (4/5). Computerized tomography showed increased orbital fat haziness and enlargement of EOM. Treatment with a combination of oral antibiotics and steroids or antihistamines resulted in resolution of signs and symptoms after 3-5 days. Intradermal and/or skin prick allergy tests were positive for hyaluronidase and negative for all other perioperative medications used.

CONCLUSION

Although uncommon, allergy to peribulbar hyaluronidase injected during cataract surgery should be considered in the differential diagnosis of patients who present with acute post-operative orbital signs and symptoms.

Rosai-Dorfman disease recurrence with bilateral orbital masses following immunosuppressant therapy

Rosai-Dorfman disease is a rare condition characterised by massive lymphadenopathy involving the orbit in 11% of cases. Immunohistochemical analysis remains key to the diagnosis with characteristic immunohistochemical S100 staining of histiocytes and lymphocyte phagocytosis. We report the case of a 43-year-old female with recurrence of bilateral orbital Rosai-Dorfman disease following long-term immunosuppressant therapy. Long-term follow-up is advised in conservatively managed patients and surgery may offer more definitive treatment.

Ptosis and Orbital Fat Prolapse after Posterior Sub–Tenon’s Capsule Triamcinolone Injection

PURPOSE

To describe the occurrence of orbital fat prolapse and blepharoptosis after posterior sub-Tenon (PST) triamcinolone injection.

DESIGN

Retrospective review of consecutive case series.

PARTICIPANTS

Patients with ptosis and orbital fat herniation after PST triamcinolone injection.

METHODS

Charts of all patients with ptosis and orbital fat herniation presenting after PST triamcinolone injection to the oculoplastics service of the Cole Eye Institute between 1999 and 2003 were reviewed. Charts were reviewed for patient age, indication, dates of injections, time to patient complaint or time to referral for ptosis, and marginal reflex distance (MRD1).

MAIN OUTCOME MEASURES

Ptosis and orbital fat herniation after PST triamcinolone injection.

RESULTS

Eleven patients with a history of ipsilateral PST triamcinolone injections were seen with ptosis and orbital fat prolapse. Ten charts were available for review. Mean patient age was 64 years (range, 45-78 years). Patients underwent 1 to 9 ipsilateral injections, and 2 patients underwent bilateral injections. Patients were seen for ptosis evaluation on average 22.5 months (range, 3-56 months) after the initial injection, and 6.6 months (range, 0-20 months) after the most recent injection. All patients demonstrated significant orbital fat prolapse in conjunction with statistically significant ptosis (P = 0.016). Tissue was obtained in 3 cases. Histologic findings in 1 case showed orbital fat infiltrated by histiocytes that seemed to contain phagocytosed material.

CONCLUSIONS

Posterior sub-Tenon triamcinolone injection may cause ptosis associated with orbital fat prolapse. This finding may be a relatively common complication of PST triamcinolone injection. We recommend counseling patients about this risk before PST triamcinolone injection.

Periocular petrolatum

PURPOSE

This report describes the clinical and histopathologic features and discusses the diagnostic difficulties and management of periocular deposition of petrolatum-based materials.

METHODS

Excision of orbital and eyelid tissue, tissue processing, and histopathologic examination was performed in patients with deposition of petroleum-based products. Transmission electron microscopy was performed in 3 cases.

RESULTS

Between 1983 and 2003, 11 patients were diagnosed with periocular petrolatum deposition, based on clinical history and the characteristic histopathologic features of polymorphic dropout spaces, and varied from a noninflammatory lesion (paraffinoma) to those with an associated granulomatous inflammatory reaction.

CONCLUSIONS

The diagnosis of petrolatum deposition can be challenging due to the range of symptoms and variable delay in presentation. Petrolatum products should be avoided during surgery and used judiciously in the postoperative period. To avoid confusion with nonspecific cases of lipogranulomatous inflammation, the terms "ointment granuloma" or "orbital paraffinoma" should be used to refer to patients presenting with orbital/eyelid lesions caused by ointment use.

Angioedema related to the use of hyaluronidase in cataract surgery

PURPOSE

To report a series of cases of angioedema related to the use of hyaluronidase in cataract surgery.

DESIGN

Observational case series.

METHODS

Three eyes of three patients who had periorbital angioedema after phacoemulsification at the Mayo Clinic, Rochester, Minnesota, between April 2001 and May 2002 were retrospectively skin tested for allergies using the prick technique.

RESULTS

Skin testing was positive in all three patients for allergy to hyaluronidase (150 U/cc) and histamine control; and negative for prick control, 2% lidocaine, 1% cyclopentolate, 2.5% neosynephrine, 0.5% proparacaine, 0.3% ofloxacin, and thimerosal.

CONCLUSIONS

The use of hyaluronidase in ophthalmic anesthesia injection may cause immediate type hypersensitivity reactions such as angioedema.

Hyaluronidase allergy after peribulbar anesthesia with orbital inflammation

A 70-year-old woman previously exposed to hyaluronidase during ophthalmic surgery had excision of hypertrophic bulbar conjunctival tissue in the right eye. Hyaluronidase was added to the peribulbar anesthetic agent. Five days postoperatively, the patient presented with proptosis in the right eye, extraocular muscle restriction, and decreased visual acuity. She was apyrexial with a normal white cell count; computed tomography of the orbits showed a diffuse increase in soft tissue density. Clinical features were unchanged after 24 hours of intravenous antibiotics, but subsequent administration of high-dose oral steroids led to clinical improvement.

Sclerosing lipogranuloma of the orbit after periocular steroid injection

PURPOSE

To report the clinical and histopathologic findings of a large sclerosing lipogranuloma of the orbit arising after a sub-Tenon's corticosteroid injection.

DESIGN

Interventional case report and review of the literature.

METHODS

A complete ocular and systemic evaluation was performed on a 81-year-old patient, who developed a large orbital mass subsequent to a periocular corticosteroid injection producing proptosis, ptosis, and ocular motility impairment. The lesion was biopsied and submitted for histopathologic analysis.

MAIN OUTCOME MEASURES

Orbital, computed tomography, and histopathologic findings.

RESULTS

Histopathologic examination revealed lipogranulomatous inflammation. Specifically, this type of reaction was consistent with a diagnosis of sclerosing lipogranuloma.

CONCLUSIONS

It is extremely rare to find a large granulomatous orbital lesion arising subsequent to a periocular corticosteroid injection. Only one case has been reported in the English-language literature to date. It is important to include this type of lesion in the differential diagnosis of an orbital mass seen after the injection of periocular corticosteroids.

Proptosis after retrobulbar corticosteroid injections

PURPOSE

This report describes the clinical, radiographic, and histopathologic findings in patients with proptosis secondary to lipomatosis after retrobulbar corticosteroid injection.

DESIGN

Retrospective, noncomparative, interventional case series and review of the literature.

METHODS

Five patients who developed symptomatic unilateral proptosis after steroid injection were studied and the literature was reviewed.

RESULTS

No previous description was found in the literature. All five cases were studied with computed tomography, and two cases were confirmed with histopathology. No fibrosis or granulomatous inflammation was identified.

CONCLUSIONS

Orbital lipomatosis is a potential complication of retrobulbar steroid injections. Symptomatic relief can be provided by a transconjunctival approach to the lower lid fat compartment.

Severe ocular and orbital toxicity after intracarotid injection of carboplatin for recurrent glioblastomas

BACKGROUND

Glioblastoma is a malignant tumor that occurs in the cerebrum during adulthood. With current treatment regimens including combined surgery, radiation and chemotherapy, the average life expectancy of the patients is limited to approximately 1 year. Therefore, patients with glioblastoma sometimes have intracarotid injection of carcinostatics added to the treatment regimen. Generally, carboplatin is said to have milder side effects than cisplatin, whose ocular and orbital toxicity are well known. However, we experienced a case of severe ocular and orbital toxicity after intracarotid injection of carboplatin, which is infrequently reported.

CASE

A 58-year-old man received an intracarotid injection of carboplatin for recurrent glioblastomas in his left temporal lobe. He complained of pain and visual disturbance in the ipsilateral eye 30 h after the injection. Various ocular symptoms and findings caused by carboplatin toxicity were seen.

RESULTS

He was treated with intravenous administration of corticosteroids and glycerin for 6 days after the injection. Although the intraocular pressure elevation caused by secondary acute angle-closure glaucoma decreased and ocular pain diminished, inexorable papilledema and exudative retinal detachment continued for 3 weeks. Finally, 6 weeks later, diffuse chorioretinal atrophy with optic atrophy occurred and the vision in his left eye was lost.

CONCLUSION

When performing intracarotid injection of carboplatin, we must be aware of its potentially blinding ocular toxicity. It is recommended that further studies and investigations are undertaken in the effort to minimize such severe side effects.

Severe periorbital edema secondary to STI571 (Gleevec)

STI571 (imatinib mesylate; Gleevec) is a selective inhibitor of the bcr-abl, c-kit, and platelet-derived growth factor receptor tyrosine kinases. Mild periorbital edema has been noted as a common side effect in Phase I and II trials of this drug for the treatment of patients with chronic myelogenous leukemia and gastrointestinal stromal tumors. The authors report the case of male patient age 63 years who developed severe periorbital edema after treatment with STI571 for chronic myelogenous leukemia. His edema was severe enough to cause visual obstruction due to lower eyelid festoons that ultimately required surgical debulking. Histopathologic analysis of specimens of the excised upper and lower eyelid tissue revealed dermal dendrocytes that expressed the platelet-derived growth factor receptor and c-kit tyrosine kinases, suggesting a possible role for dermal dendrocytes in the development of this toxic effect.

Lower eyelid herniation of orbital fat may complicate periocular corticosteroid injection

PURPOSE

To report a case of lower eyelid herniation of orbital fat occurring after periocular corticosteroid injection.

DESIGN

Interventional case report.

METHODS

A 44-year-old man with asymmetrical pars planitis complicated by right cystoid macular edema was treated with multiple right orbital floor injections of triamcinolone through the lower eyelid.

RESULTS

Right lower eyelid orbital fat herniation occurred during the course of the treatment.

CONCLUSION

A herniation of orbital fat may complicate the injection of corticosteroid through the lower eyelid.