Advances in the oculoplastic techniques have emerged to treat an array of conditions affecting the orbit, eyelids, tear ducts and face. Experts shared their own experiences with current oculoplastic practices at a symposium held at the 34th Congress of Asia-Pacific Academy of Ophthalmology (APAO 2019) in Bangkok, Thailand. Their methods were developed to address several conditions that arise in practice, such as the management of trigeminal nerve hypesthesia and recurrent conjunctival hyperemia.
Based on a presentation titled, “Trigeminal Nerve Hypesthesia: A Sign of Bad Things” by Dr. Daniel Rootman, assistant professor from Jules and Doheny Eye Institutes.
Trigeminal nerve hypesthesia is characterized by a postoperative loss of sensitivity, partially affecting the corresponding nerve. According to Dr. Daniel Rootman, this may be a sign of severe, often occult and potentially fatal disease. Therefore, testing for numbness is critical in orbital evaluation.
“Obstacles in assessing trigeminal nerve hypesthesia can be found in larger nerves and more unmyelinated fibers,” reported Dr. Rootman. “Redundancy in the nerve also means clinical impact is not as noticeable. This can lead to less common occurrences and assessments for this particular condition.”
While less commonly presented in oculoplastics, trigeminal nerve hypesthesia tends to be severe when it does occur. This is because clinical symptoms do not usually appear until greater damage has already been done. It also tends to be more subject to perineural spread due to a greater number of nerve endings versus motor nerves.
Severity was exemplified by a greater than 50% mortality rate in Dr. Rootman’s case series. He concluded that it’s important to keep awareness up in evaluating cranial V palsies. Otherwise, it could be a sign of bad things to come.
Based on a presentation titled, “Sebaceous Cell Carcinoma: The Big Picture” by Dr. Weerawan Chokthaweesak, Faculty of Medicine at Ramathibodi Hospital.
Sebaceous cell carcinoma is an uncommon, malignant tumor that occurs in the eyelid and can often be deadly. Without correct diagnosis and proper treatment, sebaceous cell carcinoma can lead to poorer outcomes. Therefore, as recommended by Dr. Chokthaweesak, it is important to first differentiate malignant from benign tumors with a proper biopsy.
“Malignant lesions often tend to outgrow their blood supply with distortions in normal eyelid architecture,” stated Dr. Chokthaweesak. “What may look like a chalazion can often appear benign on the outside. However, it is always important to look inside the eyelid and obtain a biopsy if any doubt or suspicion arises.” Dr. Chokthaweesak further discussed performing a full-thickness eyelid biopsy where a permanent section is required for the correct diagnosis.
Sebaceous cell carcinoma commonly presents in the elderly. In the young, however, sebaceous cell carcinoma is clinically associated with Muir-Torre Syndrome (MTS), a rare disorder with sebaceous neoplasia and visceral malignancy. Overall, Dr. Chokthaweesak reinforced correct diagnosis, proper investigation and prompt treatment especially in cases that may need more clarification.
Based on a presentation titled, “Recurrent Conjunctival Hyperemia with Ptosis as Symptoms of Systemic Amyloidosis” by Dongmei Li, professor at Beijing TongRen Eye Center.
Amyloidosis is a disorder of protein folding in which normally soluble protein fibrils are deposited as insoluble amyloid protein fibrils within the extracellular tissues. It can be defined as localized (specific organs and tissues) or systemic (widespread effects). “This can lead to conjunctival amyloidosis which can present with hyperemia, bumpy ptosis, proptosis, and infiltration and diffusion,” as experienced by Dr. Li.
Orbital amyloidosis is almost always localized. According to her case study, Dr. Li stated that only 6% of cases exhibited systemic disease which can often lead to serious complications and poor prognosis. “For this reason, a histological diagnosis of amyloidosis should prompt further investigation to exclude systemic involvement,” explained Dr. Li.
In one of her cases, a patient showed recurrent conjunctival congestion and prolapse for six years with ptosis that worsened for four years. She reported that excision of papillomatous conjunctival lesion and left levator resection and advancement was critical for her patient case. Dr. Li advised debulking of the amyloid and debriding deposits while making sure to respect the tissue planes and preserve eyelid tissue.
Based on a presentation titled, “Challenging Conventions: Do Dermal Fillers Even Have A Role in Orbital Disease?” by Dr. Tomoyuki Kashima, Head Director of Oculo Facial Clinic in Tokyo.
Filler injections for the periorbital region are often used for eyelid scars, expansion, and volume increases. While various methods have been developed for different conditions, Dr. Tomoyuki presented his case series for the use of dermal fillers. In his own practice, he mentioned the use of hyaluronic acid gel injections due to its reversibility and fewer complications.
Dermal fillers were successfully implemented in the correction of eyelid ectropion after a facial burn for one patient. Another case showed that visual acuity was even improved in the treatment of an upper eyelid retraction after reconstruction following sebaceous carcinoma. One patient with a facial burn just after birth with lower eyelid ectropion experienced improved function and appearance after injection.
Another 70-year-old patient with facial nerve palsy was given filler injection for synkinesis. “She was given a filler injection which yielded improvements in asymmetrical facial expression and reduced overacting muscles,” reported Dr. Kashima. “The shape of her mouth was more symmetrical after injection.”
Dr. Tomoyuki concluded that dermal filler injection to the periorbital area is effective for changing the contour of the upper eyelid, lower eyelid, and overall facial expression. Because the filler injection is easy, fast and cheap compared with surgery, it is useful for both patients and doctors.
Based on a presentation titled, “Is This Orbital Inflammation… Or Something Else?” by Dr. Morgan Yan, from the Singapore National Eye Centre.
Orbital inflammation is a descriptive term but makes no reference to the underlying disease process. This can often raise questions of whether there is true inflammation or something else occurring. Additionally, there is also the question of what may be causing the inflammation.
When the inflammatory picture is more aggressive in appearance, Dr. Yan advised to always think of an infective process. “Orbital cellulitis is commonly mistaken for conjunctivitis with an accompanying viral flu accounting for fever in children,” explained Dr. Yan. “This is because symptoms in children can often be less florid and more atypical.” He also mentioned that specialists should also keep in mind the possibility of community acquired MRSA, which can prove to be quite resistant.
Pitfalls in orbital cellulitis include awareness of atypical organisms and a less “angry-looking” clinical pictures in children. In cases of “pseudotumors”, it is important to always biopsy when in doubt, exclude malignancy, and be wary of concurrent pathologies, according to Dr. Yan. She concluded her discussion with recommendations to construct a list of differentials after careful clinical evaluation.
Based on a presentation titled, “Unusual Caruncular Mass Lesions” by Dr. Rajendra Maurya, assistant professor of ocular oncology and oculoplasty at Banaras Hindu University, Varanasi, India.
Caruncular neoplasms are rare despite their diverse histological composition. As stated in Dr. Maurya’s experience: “Ninety-five percent of caruncular mass lesions are benign while the other 5% of biopsied caruncular mass lesions end up malignant.”
Caruncular epithelial inclusion cyst is a common condition where small lesions are usually asymptomatic. However, observation, monitoring and surgical excision are recommended by Dr. Maurya. “Lobular capillary hemangioma is usually seen in early childhood with spontaneous regression being reported in some cases.” He also recommended watching out for hemangioma which can present as a diffuse, soft, cherry red mass, adherent to the globe in left caruncular area.
Caruncular mass lesions are rare although diagnosis is difficult in pre-malignant and malignant cases. However, most cases are benign in nature. Papilloma, hemangioma and nevus account for the majority of benign tumors, while sebaceous cell carcinoma is the most common caruncular malignancy. Some caruncular malignant lesions have a benign aspect, hence the need for careful monitoring, close photographic follow-up and early complete excision when necessary.
Editor’s Note: The APAO 2019 Congress was held in Bangkok, Thailand, on March 6-9, 2019. Reporting for this story also took place at APAO 2019. Media MICE Pte Ltd, PIE Magazine’s parent company, was the official media partner at APAO 2019.
