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Biomedical subjects

Dwight R Kulwin

Publications and source records attributed to Dwight R Kulwin.

At least 19 recordsLinked to original sources
PubMed2005

A case of primary adenocarcinoma of the lacrimal sac.

PURPOSE: To present a rare case of adenocarcinoma arising from the lacrimal sac. DESIGN: Interventional case report. METHODS: Report of a new case of primary lacrimal sac adenocarcinoma. RESULTS: The clinical presentation, workup, surgical treatment and pathology of a case of adenocarcinoma of the lacrimal sac are described. CONCLUSION: Although very rare, these tumors should be in the differential diagnosis of any lacrimal sac mass, especially those presenting above the medial canthal tendon. Other common features include expressible blood from the punctum, lack of pain, and a history of chronic epiphora or intermittent dacryocystitis. Local destruction and metastatic spread can be prevented by a high index of suspicion and early intervention.

Adenocarcinoma↗
PubMed2005

Dacryocystoceles in the aftermath of Stevens-Johnson syndrome.

Although Stevens-Johnson syndrome has been reported to result in canalicular and nasolacrimal duct obstruction, reports of dacryocystocele formation are lacking. We describe the occurrence and management of bilateral dacryocystoceles related to Stevens-Johnson syndrome. A 45-year-old man, recovered from Stevens-Johnson syndrome, presented with bilateral medial canthal masses and intermittent overlying facial cellulitis. Examination revealed severe keratitis sicca with extensive corneal scarring, cicatricial occlusion of all puncta, and palpable medial canthal masses bilaterally. Computed tomography demonstrated bilateral cystic masses consistent with dacryocystoceles. Bilateral lacrimal sac/cyst excision was attempted, but the left cyst recurred within 6 months after surgery. A dacryocystorhinostomy was then performed, effectively marsupializing the cyst. The puncta were not canalized and stents were not placed. The masses have not recurred with 2 years of follow-up. Dacryocystoceles may arise in the setting of Stevens-Johnson syndrome. Successful management may be achieved with marsupialization to the nasal cavity (dacryocystorhinostomy).

Dacryocystitis↗
PubMed2005

Bowen disease of the eyelid successfully treated with imiquimod.

We present a case of Bowen disease affecting the eyelid that was successfully treated with imiquimod. The clinical presentation, histopathology, and treatment of this case are presented. The tumor was treated with imiquimod for 3 months, leading to complete resolution of the disease both clinically and histopathologically. There was no evidence of recurrence 5 months after treatment cessation. Imiquimod was safely used on the eyelid in this case and may avoid extensive periocular tumor excision and reconstruction in Bowen disease.

Administration, Topical↗
PubMed2005

Unilateral frontalis sling for the surgical correction of unilateral poor-function ptosis.

PURPOSE: To evaluate the functional and cosmetic results after frontalis sling repair for unilateral ptosis associated with either poor levator function or synkinesis. METHODS: Preoperative and postoperative photographs and records of 127 patients who underwent unilateral frontalis sling ptosis repair were retrospectively reviewed. An eyelid crease incision was used in all cases, with suturing of the sling material directly to tarsus. RESULTS: Preoperative diagnosis for all patients was either unilateral poor-function blepharoptosis or ptosis associated with levator synkinesis. Underlying causes included 75 congenital, 13 posttraumatic, 11 congenital "jaw-winking," 10 cranial nerve III palsies, 9 myasthenia gravis, 5 chronic progressive external ophthalmoplegia, and 4 congenital "double-elevator" palsies. There was a mean follow-up of 11.6 months. Twenty-eight eyelids required reoperation: 11 for undercorrection, 6 for overcorrection with keratopathy, 2 for upper eyelid crease revision, 7 for correction of poor contour, 1 for a broken sling, and 1 for removal of an infected exposed polytetraflouroethylene sling. Lagophthalmos of greater than 2 mm was noted in 18 patients, 5 of whom had persistent keratopathy requiring reoperation. No other complications were reported, except for 1 suture granuloma. Good to excellent final postoperative eyelid height was achieved in 121 patients (95%) after all surgeries and with conscious recruitment of the frontalis muscle. A large majority of patients and/or parents expressed satisfaction with the final cosmetic result and were not bothered by any asymmetric lagophthalmos in downgaze or lack of a synchronous blink. However, 19 of 25 amblyopic patients were less satisfied with passive eyelid height as they failed to recruit the ipsilateral frontalis muscle to activate the sling during binocular viewing. In 17 of these 19 patients, good to excellent eyelid height could be achieved with conscious active brow elevation. CONCLUSIONS: Unilateral sling provides good to excellent functional and cosmetic results in unilateral poor-function ptosis. However, patients with amblyopia usually require conscious effort to activate the frontalis muscle to achieve satisfactory eyelid height.

Adolescent↗
PubMed2004

Primary Nocardia brasiliensis of the eyelid.

PURPOSE: To report a rare case of lymphocutaneous Nocardia brasiliensis originating in the eyelid. DESIGN: Observational case report. METHODS: The clinical presentation, workup, and treatment of a case of lymphocutaneous Nocardia brasiliensis originating in the eyelid are presented. RESULTS: The patient presented with a preseptal cellulitis from an abrasion of the eyelid that progressed to submandibular lymph node suppuration. Culture was performed, and a diagnosis of lymphocutaneous Nocardia brasiliensis was made. CONCLUSION: Nocardia brasiliensis may cause a lymphocutaneous infection of the face and must be considered in the differential diagnosis of preseptal cellulitis.

Aged↗
PubMed2004

Enucleation versus preservation of blind eyes following plaque radiotherapy for choroidal melanoma.

BACKGROUND: Currently available information about patients with posterior uveal melanoma treated by plaque radiotherapy is insufficient to determine what to do about eyes that become blind as a consequence of the tumour and its treatment. Should they be enucleated, or is ocular preservation just as good in terms of survival? METHODS: We performed a retrospective survival analysis of secondary enucleation versus ocular preservation in patients with a posterior uveal melanoma treated by plaque radiotherapy whose irradiated eye became completely blind following that treatment. Of the 79 patients who fulfilled defined inclusion criteria, 25 underwent secondary enucleation of the blind eye, and 54 retained their irradiated blind eye. RESULTS: Most of the baseline demographic and tumour-related variables evaluated were similarly distributed between the subgroups. The 5-year, 10-year and 15-year all-cause death rates in the secondary enucleation subgroup were 24.7%, 51.5% and 52.0% respectively, and those in the ocular preservation subgroup were 7.4%, 32.9% and 48.1% respectively. In spite of the apparent slight difference between the curves, the difference was not statistically significant (p = 0.41, Mantel-Haenszel test). INTERPRETATION: Although a retrospective study of this type has several limitations, our results suggest that secondary enucleation is not likely to substantially improve survival of patients whose irradiated eye becomes totally blind following plaque radiotherapy for choroidal or ciliochoroidal melanoma.

Blindness↗
PubMed2004

Effect of unilateral blepharoptosis repair on contralateral eyelid position.

PURPOSE: This study evaluates the effect of unilateral blepharoptosis repair on contralateral eyelid position and assesses the relation between preoperative eyelid height interdependence, consistent with Hering law, and surgical outcome. METHODS: The medical records of 54 patients (21 men, 33 women; mean age, 65 years) who underwent external levator advancement for unilateral aponeurotic blepharoptosis were reviewed for preoperative and postoperative margin reflex distance (MRD) of the nonoperated eye. To assess the relation between preoperative Hering dependence (mechanical elevation of the ptotic eyelid causing a decrease in contralateral eyelid height) and postoperative eyelid position, the change in MRD of the nonoperated eye was compared between subjects who on preoperative evaluation did (n=18) and did not (n=36) demonstrate eyelid height interdependence, using the 2-sample t test. RESULTS: After unilateral blepharoptosis repair, the mean (+/- SD) change in contralateral MRD was -0.2 +/- 0.8 mm. There was no significant difference in contralateral MRD change in subjects with and without preoperative Hering dependence (-0.3 +/- 0.8 mm versus -0.2 +/- 0.9 mm, respectively, p=0.78). Seventeen percent (9 of 54) of patients had a contralateral MRD decrease of more than 1 mm. Three patients (5.6%) required contralateral blepharoptosis repair within 1 year of initial surgery. CONCLUSIONS: After levator advancement for unilateral blepharoptosis, roughly 17% of patients will have a decrease in contralateral eyelid height of more than 1 mm, with 5% of patients requiring surgical repair during the first postoperative year. The degree of change in contralateral eyelid height cannot be reliably predicted by preoperative assessment of Hering dependence.

Aged↗
PubMed2003

Monitored anesthesia care for enucleations and eviscerations.

OBJECTIVE: To report the technique and success of using monitored anesthesia care instead of general anesthesia for ocular enucleation and evisceration surgeries. DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: Twelve enucleated patients (Soparkar and Patrinely) and 146 eviscerated patients (Kulwin and Kersten). METHODS: Surgical logs of two oculoplastic practices were reviewed searching for cases of ocular enucleations and eviscerations performed under monitored anesthesia care between 1990 and 2001. Identified hospital and clinic charts were then reviewed. MAIN OUTCOME MEASURES: Monitored anesthesia care was deemed successful if (1) there were hemodynamic stability and complete analgesia intraoperatively; (2) there was absence of any chart documentation regarding patient or family psychological distress over the anesthesia method used; and (3) patients were discharged from the hospital without the need for observation or treatment > or = 23 hours. RESULTS: Between 1990 and 2001, 146 eviscerations were performed under local anesthesia with monitored anesthesia care by two surgeons (RCK, DRK) as their routine practice pattern. In 1996, Drs. Soparkar and Patrinely began performing enucleations under monitored anesthesia care in selected cases, and from 1996 to 2001, these surgeons enucleated 12 patients under monitored anesthesia care. Four of the enucleated patients requested surgery without general anesthesia. The remaining eight patients had been refused surgery by at least one other specialist because of the patient's perceived high medical risk for complications under general anesthesia. In all 158 patients, the procedures were deemed successful by the preceding criteria. CONCLUSIONS: This four-surgeon case series reports the successful use of local anesthesia with monitored care for ocular enucleation and evisceration procedures, offering several potential advantages over the traditional use of general anesthesia.

Adolescent↗
PubMed2003

Malignant mesenchymoma of the orbit: case report and review of the literature.

OBJECTIVE: Malignant mesenchymoma are rare tumors of the orbit. From 1961 using English-language literature, we present the sixth such case and the first case with three malignant components. DESIGN: Interventional case report. METHODS: The clinical presentation, workup, surgical treatment, and pathology of a case of malignant mesenchymoma of the orbit are presented. RESULTS: Although very rare, these tumors should be in the differential diagnosis of any tumor of the orbit. The prognosis is unknown because of the lack of follow-up of reported patients. CONCLUSIONS: This malignant orbital mesenchymoma, an entity not accepted by all pathologists, was more complex than cases previously reported in the English literature in demonstrating rhabdomyosarcomatous, chondrosarcomatous, and osteogenic differentiation.

Aged↗
PubMed2003

Solitary fibrous tumor of the orbit: is it rare? Report of a case series and review of the literature.

PURPOSE: The real incidence of solitary fibrous tumor (SFT) of the orbit is unknown, but it seems that since it was first described in 1994, orbital SFT has been increasingly recognized. We believe that the orbital SFT is a relatively common tumor and that it should be considered in the differential diagnosis of any orbital tumor. DESIGN: Interventional case series. PARTICIPANTS: Four new cases of orbital SFT. METHODS: Four patients affected by solitary fibrous tumor of the orbit are described. One patient experienced a recurrent SFT shortly after initial surgical excision performed elsewhere. Thirty-eight cases have been reported in the literature in 7 years. RESULTS: The number of orbital SFTs reported has been increasing, reaching an average of more than five tumors reported per year. Since the first orbital SFT was described in 1994, 37 cases have been reported in the literature. We add four new cases in our series, including a recurrent tumor. A total of 42 cases have now been described, eight with recurrences. Malignant transformation occurred in one case. CONCLUSIONS: We believe that before 1994, the diagnosis orbital SFT was confused with other benign orbital tumors, such as fibrous histiocytoma and hemangiopericytoma because of a lack of use of immunohistochemical techniques. This entity should now be considered relatively common and should be included in the differential diagnosis of orbital tumors in any age group. Local recurrences of SFT are possible and usually follow an incomplete initial excision. Recurrent tumors in the orbit have shown the tendency to infiltrate the surrounding tissues and the bone, rendering complete secondary excision more difficult. Recurrent orbital SFT also has the potential for malignant transformation. The treatment of choice of orbital SFT is complete surgical excision and careful follow-up. Considering the more aggressive course followed by recurrent tumor, correct diagnosis and management is essential.

Adult↗
PubMed2003

Osteogenic sarcoma after orbital radiation rhabdomyosarcoma.

PURPOSE: We describe the occurrence of maxillary and orbital osteogenic sarcoma in a child after treatment of contralateral orbital rhabdomyosarcoma with external beam radiation and chemotherapy. DESIGN: Interventional case report. INTERVENTION: Treatment of a maxillary and orbital rhabdomyosarcoma with surgical resection, systemic chemotherapy, and local radiation. MAIN OUTCOME MEASURES: Occurrence and histology of secondary malignancy after orbital radiation. RESULTS: An eleven year-old male presented for evaluation of left facial swelling, occurring ten years after successful treatment of a right orbital embryonal rhabdomyosarcoma with chemotherapy and 5040 cGY of external beam radiation. Computerized tomography demonstrated a mass involving the left maxillary sinus and orbital floor. Biopsy demonstrated osteogenic sarcoma. Despite attempted total excision with radical maxillectomy, resection margins were found to have microscopic extension of the tumor. Postoperatively he was treated with systemic chemotherapy and local radiation. Eight months postoperatively he remains alive despite local progression. CONCLUSIONS: Osteogenic sarcoma can occur as a secondary malignancy years after the successful treatment of orbital rhabdomyosarcoma with external beam radiation and chemotherapy. After orbital radiation, subjects should undergo routine lifelong examinations.

Child↗
PubMed2003

Proptosis after hair pulling.

We describe proptosis due to a subperiosteal orbital hematoma that originated from a subgaleal bleed caused by hair pulling. A 13-year-old boy presented with a one-week history of progressive proptosis after his older sister pulled his hair during an argument. Computerized tomography showed a subgaleal hematoma and a right superior subperiosteal orbital hematoma. Progressive proptosis and compressive optic neuropathy developed, necessitating surgical evacuation with a favorable outcome.Hair pulling can result in a subgaleal bleed with extension to the orbital subperiosteal space. When managing patients with a subgaleal hematoma, this vision-threatening complication should be considered and treated accordingly.

Adolescent↗
PubMed2003

Outcome and influencing factors of external levator palpebrae superioris aponeurosis advancement for blepharoptosis.

PURPOSE: To evaluate, in patients with acquired good-function blepharoptosis, levator advancement success and surgical failure risk factors. METHODS: This retrospective, case-cohort study was university based. An estimated 828 patients underwent levator advancement for acquired good-function blepharoptosis between January 1, 1990, and December 31, 1999. Seventy-two patients underwent reoperation during the first postoperative year. Of 125 randomly selected patients not undergoing reoperation, 106 met the desired outcome criteria: postoperative margin reflex distance (MRD) >/=2.0 mm and </=4.5 mm in operated eyes and </=1.0 mm asymmetry between eyelids. Mean MRD, levator function, and Hering dependence (ipsilateral eyelid elevation exacerbating contralateral blepharoptosis) prevalence were determined for reoperated and desired-outcome groups and compared by using 2-sample t test and the Fisher exact test, respectively. Multivariate analysis was also performed. RESULTS: Reoperative rates were 8.7% overall, 5.2% of unilateral, and 13% of bilateral cases. Fourteen percent of patients had results outside the desired range but declined reoperation. Univariate analysis revealed significant differences in preoperative characteristics between desired and undercorrected groups: MRD, 1.0 versus 0.32 mm (p=0.001); levator function, 15.4 versus 14.7 mm (p=0.013); and Hering dependence, 50% versus 79% (p=0.005). With multivariate analysis, bilateral blepharoptosis was statistically significant (p=0.014), whereas levator function and Herring dependence were not. No differences were seen between desired and overcorrected groups. CONCLUSIONS: After levator advancement for acquired good-function blepharoptosis, 77% of patients had ideal results and 8.7% underwent reoperation. Patients with bilateral or severe blepharoptosis have increased risk of undercorrection.

Adult↗
PubMed2002

Isolated unilateral neurogenic blepharoptosis secondary to eyelid trauma.

PURPOSE: To describe eyelid trauma as a cause of isolated neurogenic blepharoptosis. DESIGN: Observational case series. METHODS: Three previously healthy patients (two male and one female; aged 29 to 39 years) were evaluated for unilateral blepharoptosis following forceful anterior displacement of the upper eyelid. Two injuries occurred during domestic altercations and one while the patient was playing basketball. RESULTS: All three patients had complete unilateral upper eyelid ptosis with no levator palpebrae superioris function, consistent with loss of innervation. Additional findings included minimal eyelid ecchymosis, eyelid edema, and subconjunctival hemorrhage in two cases. The remainder of the examinations was unremarkable with full ocular motility and no anisocoria. Without treatment, within 2 weeks, all three patients recovered completely with normal symmetric lid height and levator function. CONCLUSIONS: Isolated neurogenic blepharoptosis may result from traumatic anterior upper eyelid displacement. Resolution is likely within 2 weeks.

Blepharoptosis↗
PubMed2002

Routine histopathologic evaluation of the lacrimal sac during dacryocystorhinostomy: how useful is it?

OBJECTIVE: To determine the usefulness of "routine" lacrimal sac biopsy to evaluate unsuspected neoplasm or systemic disease in patients with acquired nasolacrimal duct obstruction. DESIGN: Noncomparative, interventional case series with histopathologic correlation. PARTICIPANTS: Review of charts revealed histopathologic reports on 302 specimens from 258 patients who had undergone routine dacryocystorhinostomy for clinical acquired nasolacrimal duct obstruction. INTERVENTION: Dacryocystorhinostomy (DCR) with histopathologic evaluation of lacrimal sac. MAIN OUTCOME MEASURES: The following variables were extracted from the medical records: age, gender, presenting symptoms, history of predisposing conditions, lacrimal system abnormalities noted before surgery, dye disappearance test, dacryocystogram or dacryoscintillogram, appearance of the lacrimal sac during surgery, and histopathologic report of the lacrimal sac specimen. RESULTS: Findings of histopathologic evaluation of 302 lacrimal sac specimens from 170 females and 88 males who had undergone routine DCR were reviewed. Evidence of systemic disease or neoplasia involving the lacrimal sac was present in 10 specimens. All 10 positive specimens had a grossly abnormal appearing sac at the time of surgery (n = 8), a known preexisting history of systemic diseases (n = 6), or both. The remaining 292 specimens showed chronic inflammation, fibrosis, or normal mucosa. CONCLUSIONS: Only patients with known preexisting systemic disease or a grossly abnormal lacrimal sac had "positive" histopathologic findings. We recommend that lacrimal sac biopsy in patients undergoing DCR should be performed only in those with a positive history for systemic disease or an abnormal-appearing lacrimal sac during surgery.

Adolescent↗
PubMedDate not supplied

Isolated medial orbital wall fractures with medial rectus muscle incarceration.

PURPOSE: To retrospectively review and analyze cases of isolated medial orbital wall fractures with medial rectus muscle incarceration presenting to a tertiary ophthalmic plastic surgery practice from 1997 to 2005. METHODS: Retrospective chart review and literature review. RESULTS: Nine cases of isolated medial wall fracture with medial rectus muscle incarceration are presented. The most frequently encountered clinical feature was adduction deficit on the affected side. Extraocular motility improved in all patients who underwent surgery, and mean postoperative enophthalmos was minimal. CONCLUSIONS: Isolated medial orbital wall fractures with medial rectus muscle incarceration are rare. Ocular motility abnormalities were the only indication of underlying fracture in the majority of our cases. Clinicians should be alerted to the anticipated presentation of medial wall fractures with incarceration of the medial rectus muscle, including the possibility of a "white eye" and normal abduction of the traumatized eye.

Adolescent↗