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PURPOSE: Staging of cancer is essential to formulate appropriate treatment plans and to help predict prognosis. A solitary region of increased radionuclide uptake ("hot spot") on a bone scan may represent a metastasis or a masquerading lesion. Biopsy may be required to determine its histologic nature, but localization of the site may be difficult because bone scans provide poor spatial resolution. METHODS: In two patients with breast carcinoma, radioactive technetium was administered intravenously and a gamma probe was used preoperatively and intraoperatively to identify the site of cranial bone involvement. RESULTS: The lesions were resected; one was a benign fibro-osseous lesion and one was a metastatic breast adenocarcinoma. CONCLUSIONS: A gamma probe may be helpful in localizing the site of radioactive uptake identified by bone scan.

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PURPOSE: The position of the globe relative to the orbital rim plays a significant role in the relationship between the eyelids and the cornea. A prominent globe (relative proptosis) may cause eyelid retraction and exposure keratopathy. Simple horizontal lower eyelid tightening exacerbates eyelid retraction. Optimal correction with an orbital decompression or advancement of the orbital rim entails considerable risk. A technically simpler alternative, placement of an orbital rim onlay implant, was evaluated. METHODS: Fourteen patients with symptomatic relative proptosis underwent placement of a porous polyethylene orbital rim onlay implant. RESULTS: Lower eyelid position, exposure keratopathy, and ocular discomfort were improved in all patients. Two patients required minor surgical revisions. CONCLUSIONS: Porous polyethylene orbital rim onlay implants are a satisfactory option to treat the sequelae of relative proptosis.

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A 56-year-old woman presented with a unilateral ptosis induced by a nonembedded soft contact lens of approximately 2 years' duration. The unilateral ptosis most likely resulted form localized inflammation and the physical presence of the soft contact lens. The patient's symptoms resolved completely after double lid eversion and lens removal.

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We report the case of a 43-year-old man who presented with painless proptosis of the right eye of 6 weeks' duration. Examination demonstrated a tense right orbit and decreased vision and extraocular motility bilaterally. Diagnostic evaluation included computed tomographic imaging of the head and orbits, a therapeutic trial of high-dose systemic corticosteroids, and orbital biopsy, which revealed the presence of metastatic adenocarcinoma. The primary tumor was found to be an estrogen-receptor-positive, infiltrating ductal adenocarcinoma of the right breast. Therapy included lumpectomy of the breast mass, orbital irradiation, and hormonal therapy. Metastatic carcinoma of the breast should be considered in the differential diagnosis of orbital neoplastic disease in the male patient.

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BACKGROUND AND OBJECTIVE: Only limited volume expansion is offered by traditional lateral orbital decompressions in which the anterior segment of the lateral wall is removed to allow lateral soft tissue prolapse. A great deal of additional soft tissue expansion can be obtained, not only laterally, but also posteriorly by removing the deep portion of the sphenoid wing. The authors report their experience in removing this bone through a coronal approach. PATIENTS AND METHODS: The authors performed maximal, three-wall, orbital decompressions through a coronal approach for 20 patients with thyroid-related orbitopathy. A disfiguring proptosis resulting from stable Graves' disease orbitopathy was the indication for surgery in all cases. Through a coronal approach, the lateral rim was left in place and thinned, augmented with specialized orbital rim onlay implants, or repositioned with osteosynthesis systems. The bone over the lacrimal fossa was sculpted to form a "keyhole" for the lacrimal gland, thereby providing additional orbital expansion. Once the medial canthal tendon and lacrimal sac had been elevated from their periosteal attachment, excellent exposure was obtained for medial and inferior orbital decompression. RESULTS: The authors report the results of 20 coronal orbital decompressions during a period of 44 months. Seven cases included lateral rim advancement. Up to 6 mm of retrodisplacement was achieved without rim augmentation, 9 mm with rim augmentation. DISCUSSION: The deep lateral orbital wall can provide significant room for volume expansion. The authors found that up to 6 mm of proptosis reduction can be obtained using the lateral wall alone. The coronal approach provides access to all four orbital walls for deep orbital decompression. The authors' philosophy of treatment in cases without compressive optic neuropathy is evolving toward the use of the lateral wall as the first approach with the incorporation of additional walls as needed.

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The implantation of an orbital hydroxyapatite implant was complicated by conjunctival dehiscence, cutaneous fistula formation, and infection with Staphylococcus aureus. Pathologic examination of the sphere 2 years after its implantation revealed reduction in the size of the implant, peripheral lamellar bone formation and central necrosis. This is the first report of this constellation of complications with hydroxyapatite spheres positioned in the orbit. The 2-year interval between implantation and removal of the sphere is the longest reported in a case with histopathologic analysis.

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A 76-year-old diabetic woman presented with progressive binocular vertical diplopia and right eye pain. Examination revealed a pupil-involving partial right third cranial nerve palsy, with development of anisocoria over the course of several hours. MRI of the brain showed no mass lesion. MRA, even with retrospective review of the images, failed to clearly identify a 1 cm right posterior communicating artery aneurysm detected by subsequent conventional cerebral angiography. While MRA has been reported to be highly sensitive in cerebral aneurysm detection at some centers, other investigators have indicated less favorable data. Standardized protocols for data acquisition and meticulous attention to proper post-processing and image interpretation are essential if MRA is to supplant invasive arteriography. Currently, conventional (x-ray) angiography remains the gold standard for aneurysm detection, while MRA possesses excellent potential in this regard.

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Although transconjunctival lower eyelid blepharoplasty was described as far back as 1924 and it offers certain advantages over the skin-muscle flap, many surgeons continue to use the transcutaneous approach. This is likely due to unfamiliarity with the transconjunctival approach and general overestimation of the ability of skin excision to improve lower eyelid wrinkles. Transconjunctival lower eyelid blepharoplasty, however, continues to gain favor over the transcutaneous approach as more surgeons appreciate the absence of a visible scar and significantly lower incidence of postoperative lower eyelid retraction or change in lower eyelid margin contour, allowing a nonsurgical look.

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Ocular myasthenia is a localized form of myasthenia clinically involving only the extraocular, levator palpebrae superioris, and/or orbicularis oculi muscles. Ocular manifestations can masquerade as a variety of ocular motility disorders, including cranial nerve and gaze palsies. A history of variable and fatiguable muscle weakness suggests this diagnosis, which may be confirmed by the edrophonium (Tensilon) test and acetylcholine receptor antibody titer. Anticholinesterases, corticosteroids and other immunosuppressive agents, and other therapeutic modalities, including thymectomy and plasmapheresis, are used in treatment. As the pathophysiology of myasthenia has been elucidated in recent years, newer treatment strategies have evolved, resulting in a much more favorable prognosis than several decades ago. This review provides historical background, pathophysiology, immuno-genetics, diagnostic testing, and treatment options for ocular myasthenia, as well as a discussion of drug-induced myasthenic syndromes.

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OBJECTIVE: To describe three patients with giant cell arteritis (GCA) who suffered profound, irreversible visual loss due to delayed initiation or discontinuation of corticosteroid therapy pending results of histopathologic examination of temporal artery biopsy specimens and to review the appropriate management of GCA once the clinical diagnosis is made. STUDY DESIGN: Case series. SETTING: University-affiliated eye hospital. PATIENTS: Three women with biopsy-proven GCA and bilateral visual loss due to delayed institution or discontinuation of corticosteroid therapy. MAIN OUTCOME MEASURES: Visual acuity and onset, and time course of corticosteroid therapy. RESULTS: Permanent visual loss resulted from delayed initiation of corticosteroid therapy in two patients and discontinuation of therapy in one patient with clinically suspected diagnosis of GCA. In two of these patients, visual loss was preceded by amaurosis fugax and other visual disturbances, although one patient did not volunteer this information to her physician. CONCLUSIONS: Giant cell arteritis may cause rapid and profound loss of vision bilaterally, often without warning. It is essential that systemic corticosteroid therapy be initiated as soon as the diagnosis of GCA is made clinically. Corticosteroid therapy should not be delayed until results of examination of the temporal artery biopsy specimen are obtained. Biopsy specimen interpretation will not be affected if the biopsy is performed within 7 to 10 days of starting therapy.

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This study evaluated the effect of prostaglandin I2 (PGI2) on fibronectin-mediated macrophage phagocytosis in vivo and in vitro. Phagocytosis measured in vivo in rats by the vascular clearance rate and hepatic localization gelatinized sheep erythrocytes was inhibited in a dose-dependent manner after intravenous administration of PGI2. Phagocytosis was assessed in vitro in terms of uptake of fibronectin-dependent gelatinized sheep erythrocytes by monolayers of casein-elicited rat peritoneal macrophages. Concentrations of 1 ng/ml PGI2 or greater resulted in inhibition of particle internalization but not attachment to macrophages. This inhibitory effect was enhanced by aminophylline, a phosphodiesterase inhibitor. PGI2 increased cAMP levels and these were further increased in the presence of aminophylline. These data indicate that PGI2 inhibits macrophage uptake of gelatinized particles and support the idea that this is mediated by increased intracellular levels of cyclic AMP. PGI2 should thus be considered a potential etiologic factor in the phagocytic depression observed in association with thrombosis.

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