Biomedical subjects
Publications and source records attributed to G J Gladstone.
This article explores many of the ophthalmologic aspects of thyroid-related orbitopathy. The eight main areas of clinical concern--ocular comfort, optic nerve function, exophthalmos, eyelid position, diplopia, cosmesis, soft-tissue signs, and psychologic factors--are discussed so that practitioners may be more secure in dealing with these areas and in helping patients to be more comfortable both physically and psychologically.
A modified gold-weight implantation technique was used to treat paralytic lagophthalmos in 15 patients. Three patients had suffered extrusions of previously placed gold-weight implants, two had other complications necessitating reoperation, and 10 had no previous surgery. The surgical modifications were intended to reduce the incidence of implant extrusion, postoperative ptosis, and implant visibility beneath the skin. The important changes in the surgical technique included (a) advancing the levator aponeurosis over the implant and (b) adjusting the final eyelid height intraoperatively with levator myotomies. Follow-up ranged from 6 to 11 months. None of the patients in this study had postoperative problems associated with ptosis, implant extrusion, or implant visibility. Mild, prolonged, postoperative edema was noted in several patients. This resolved spontaneously. Mild eyelid retraction and lagophthalmos were seen postoperatively in two patients. This was caused by a failure to perform marginal myotomies at the time of the initial surgeries.
Tear production resulting from obstruction of the nasolacrimal duct is a common ophthalmic problem. The diagnosis and treatment of this condition require a thorough understanding of the lacrimal apparatus and its ocular and nasal relationships. Idiopathic or primary acquired nasolacrimal duct obstruction is a syndrome of unknown etiology. Of all nontraumatic forms, it accounts for the vast majority of cases found in adults. The authors discuss a number of potential causes, some of them iatrogenic and discuss the technique of dacryocystorhinostomy, the standard surgical treatment, in detail.
Squamous cell carcinoma of the lacrimal sac is rare. We report a case of a 45-year-old Caucasian woman with a squamous cell carcinoma of the right lacrimal sac, initially presenting at an early stage. A critical review of the literature is also presented with specific regard to operative and postoperative management. Treatment of these lesions is predominantly surgical. The role of radiation therapy is not yet fully defined. Successful management requires a high index of suspicion as well as aggressive and early intervention.
Bacterial infections of the periorbital and orbital tissues range in severity from minor to life-threatening. Preseptal (periorbital) cellulitis is more common than orbital cellulitis and occurs quite frequently in children. A history of antecedent trauma or upper respiratory tract infection is present in more than half of all cases. Evaluation by computed tomography scans is an indispensable part of the diagnostic procedure. All cultures should be obtained before institution of antibiotic therapy. Initial therapy should begin with administration of broad-spectrum antibiotics with adjustments made in response to positive culture results. Response to antibiotics is usually prompt and the incidence of complications is low. If clinical improvement is slow, surgery should be performed early in the course of the disease to minimize the potential for significant complications such as cavernous sinus thrombosis.
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In a series of 18 patients operated on because of postoperative eyelid contour abnormalities or small to moderate amounts of diffuse blepharoptosis, a technique of internal vertical shortening produced consistently reliable results. A cosmetically acceptable result was achieved in 17 of 18 patients (95%); only one of 18 (5%) showed no improvement. In cases of overcorrected upper eyelid retraction secondary to thyroid ophthalmopathy, 11 of 11 patients had cosmetically acceptable results. In those with blepharoptosis or eyelid contour abnormalities secondary to other causes, six of seven patients (84%) had cosmetically acceptable results. In our technique of internal vertical shortening, a predetermined amount of conjunctiva and overlying scar tissue or levator aponeurosis is removed. The resection uses a posterior approach to remove tissue from the superior tarsal border upward.
Xanthelasma of the eyelids traditionally has been treated by excision, followed by suturing of the defect. A new technique of ablating these lesions using a superpulsed CO2 laser was used to treat a series of nine patients with xanthelasma. Advantages of this technique include: (1) superb hemostasis intraoperatively; (2) magnified view of tissue removal, enhancing complete excision; (3) the absence of suturing; (4) the avoidance of reconstructive procedures; and (5) a high degree of patient satisfaction, with minimal or no postoperative pain.
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The standard glass tube used with a conjunctivodacryocystorhinostomy is subject to spontaneous displacement. Either internal displacement into the surgically created passageway or external displacement and loss are possible. We have modified the tube by adding a flange 4 to 6 mm from the tube's top. This anchors the tube and significantly reduces postoperative tube mobility. Many procedures that would otherwise fail can be salvaged by using this new tube.
We used the Hertel exophthalmometer to measure the degree of protrusion in 681 adults, ranging in age from 18 to 91 years. The 327 white and 354 black subjects had no history of orbital or endocrine disease, severe myopia (more than -7 diopters), or buphthalmos. The mean normal protrusion values were 16.5 mm in white men, 18.5 mm in black men, 15.4 mm in white women, and 17.8 mm in black women. Although protrusion values above 21 mm are usually considered abnormal, we found that the upper limits of normal were 21.7 mm for white men, 24.7 mm for black men, 20.1 mm for white women, and 23.0 mm for black women. These differences were statistically significant (P less than .025). No individual had more than 2 mm of asymmetry between eyes.
When capillary hemangiomas do not resolve spontaneously, treatment may be indicated. Various forms of therapy have been employed. These include excisional surgery, cryotherapy, sclerosing solutions, embolization, external beam irradiation, steroids, and the argon laser. We report the use of a standard ophthalmic argon laser combined with curettage on a noninvoluting eyelid margin hemangioma found on a 29-year-old man. Details of the surgical technique are provided and postoperative results documented. We believe this to be the first case of a lid margin hemangioma successfully treated in this manner. The technique offers these advantages: (1) Selective absorption of the laser energy by the blood-filled tissue allows microablation of the lesion under ideal hemostatic conditions with minimal loss of normal lid tissue. (2) Oculoplastic lid repair is obviated since minimal normal tissue is removed. (3) The procedure can be performed under local anesthesia on an outpatient basis.
A 76-year-old man had excellent visual acuity and an afferent pupillary defect (Marcus-Gunn pupil) on one side. After several weeks of investigation, a diagnosis of biopsy-proved temporal arteritis was made. I believe that this is the first case of "occult" temporal arteritis with essentially normal vision and with an afferent pupillary defect as the sole original manifestation of the disease.
Solar retinitis after prolonged or purposeful exposure to the sun has been reported many times. In this study, three patients were seen with the clinical diagnosis of solar retinitis but without an initial compatible history. Previously, such persons have frequently been categorized as having foveomacular retinitis. In this study, careful follow-up history was obtained in an attempt to find an origin for the condition of the patients. Evidence for very brief, high-intensity, and long-term low-intensity exposure to the sun's radiant energy was substantiated. Theoretical consideration was made of the mechanisms by which this type of exposure produced retinal damage.