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Hole dynamics in spin and orbital ordered vanadium perovskites.

A theory of doped perovskite vanadates with spin and orbital orders is presented. Mobile holes are strongly renormalized by spin excitations (magnons) in the spin G-type and orbital C-type (SG-OC) order, and orbital excitations (orbitons) in the spin C-type and orbital G-type (SC-OG) one. Hole dynamics in a staggered t(2g) orbital array is distinguished from that in the antiferromagnetic order and the e(g) orbital one. The fragile character of the (SG-OC) order in Y1-xCaxVO3 is attributed to the orbiton softening induced by a reduction of the spin order parameter.

Journal Article↗

Problems with the hydroxyapatite orbital implant: experience with 250 consecutive cases.

The coral derived hydroxyapatite sphere is a popular, integrated orbital implant designed to provide improved motility of the ocular prosthesis following enucleation. Although the implant has rapidly become widely used by ophthalmologists, little information is available regarding the problems of this technique in a large series of cases. Experience with 250 consecutive cases of hydroxyapatite orbital implant use was reviewed and the problems of the implants and their management investigated specifically. The reasons for enucleation included uveal melanoma (157 cases), retinoblastoma (70 cases), blind painful eye (22 cases), and intraocular medulloepithelioma (one case). Earlier treatment to the eye was performed before enucleation in 47 cases and included repair of ruptured globe (17 cases), plaque radiotherapy (18 cases), external beam radiotherapy (six cases), and others (six cases). During a mean of 23 months' follow up (range 6-40 months), there have been no recognisable cases of orbital haemorrhage related to the implant, and no cases of implant extrusion or implant migration. There was one case of presumed orbital infection (culture negative) that resolved with intravenous antibiotics and the implant was retained within the orbit. Other problems included conjunctival thinning in eight cases managed by observation and prosthesis adjustment, and conjunctival erosion in four cases managed by combinations of scleral patch graft, conjunctival flap, and prosthesis adjustment. The conjunctival erosion was caused by a poorly fitting prosthesis in three cases and wound dehiscence in one case. The problem rate in eyes receiving prior radiotherapy or surgery was not increased. The hydroxyapatite integrated orbital implant is a well tolerated motility implant without the high rate of extrusion and infection seen with other motility implants. The prosthesis fit may contribute to the tolerance of the implant.

Child↗

Transconjunctival orbital decompression in Graves' ophthalmopathy: lateral wall approach ab interno.

AIMS: A modified surgical technique is described to perform a one, two, or three wall orbital decompression in patients with Graves' ophthalmopathy. METHODS: The lateral wall was approached ab interno through a "swinging eyelid" approach (lateral canthotomy and lower fornix incision) and an extended periosteum incision along the inferior and lateral orbital margin. In addition, the orbital floor and medial wall were removed when indicated. To minimise the incidence of iatrogenic diplopia, the lateral and medial walls were used as the first surfaces of decompression, leaving the "medial orbital strut" intact. During 1998, this technique was used in a consecutive series of 19 patients (35 orbits) with compressive optic neuropathy (six patients), severe exposure keratopathy (one patient), or disfiguring/congestive Graves' ophthalmopathy (12 patients). RESULTS: The preoperative Hertel value (35 eyes) was on average 25 mm (range 19-31 mm). The mean proptosis reduction at 2 months after surgery was 5.5 mm (range 3-7 mm). Of the total group of 19 patients, iatrogenic diplopia occurred in two (12.5%) of 16 patients who had no preoperative diplopia or only when tired. The three other patients with continuous preoperative diplopia showed no improvement of double vision after orbital decompression, even when the ocular motility (ductions) had improved. In the total group, there was no significant change of ductions in any direction at 2 months after surgery. All six patients with recent onset compressive optic neuropathy showed improvement of visual acuity after surgery. No visual deterioration related to surgery was observed in this study. A high satisfaction score (mean 8.2 on a scale of 1 to 10) was noted following the operation. CONCLUSION: This versatile procedure is safe and efficacious, patient and cost friendly. Advantages are the low incidence of induced diplopia and periorbital hypaesthesia, the hidden and small incision, the minimal surgical trauma to the temporalis muscle, and fast patient recovery. The main disadvantage is the limited exposure of the posterior medial and lateral wall.

Adult↗

Orbital rhabdomyosarcoma.

BACKGROUND: Although rhabdomyosarcoma (RMS) is a rare tumor among the entire group of mesenchymal malignancies, it is a relatively common lesion and significant challenge for the ocular oncologist in terms of its diagnosis and management. METHODS: A comprehensive literature search of articles published over the past 30 years in PubMed was conducted. RESULTS: Orbital RMS usually presents as a space-occupying lesion in the orbit during the first decade and may mimic other neoplastic or inflammatory masses. The tumor has predilection for the superior nasal quadrant of the orbit. The clinical manifestations depend on the location of the tumor within the orbit and its rate of growth. The common histopathologic types are embryonal and alveolar varieties. CT and MR imaging are important in the evaluation of this tumor. Particular attention should be placed on the bone invasion and extension of the tumor into the intracranial cavity and paranasal sinuses. Treatment usually consists of a combination of chemotherapy and radiation therapy following excisional biopsy. CONCLUSIONS: Survival of orbital RMS has improved due to advances in chemotherapy and radiotherapy. Posttreatment complications, including side effects of radiotherapy and secondary orbital malignancies, as well as visual dysfunction, occur more often and present new challenges due to improved long-term survival.

Antineoplastic Agents↗

Cytodiagnosis of multiple myeloma presenting as orbital involvement: a case report.

BACKGROUND: Plasma cell neoplasms represent autonomous proliferations of plasma cells and can manifest as diffuse myeloma with systemic involvement (plasma cell myeloma or multiple myeloma), monoclonal gammopathy of undetermined significance (MGUS), or as variants of plasma cell myeloma such as indolent myeloma, smoldering myeloma, osteosclerotic myeloma, plasma cell leukaemia and non-secretory myeloma. Localized neoplastic proliferation of plasma cells presents as solitary plasmacytoma of bone or extramedullary plasmacytoma. Involvement of orbit can occur as a solitary plasmacytoma, or as part of systemic involvement in multiple myeloma, the clinical outcome being significantly worse in the latter setting. Orbital involvement in multiple myeloma is very rare with less than 50 cases reported in the literature. Early cytological diagnosis of such lesions is vital for timely institution of appropriate therapy. As far as we are aware only six previous cases of cytological diagnosis of multiple myeloma involving the orbit are on record. CASE PRESENTATION: A 37 year old male presented with low grade fever showing evening rise, headache, diplopia and swelling in the right periorbital and temporal region. Imaging studies revealed destructive lesion of sphenoid, frontal bone and zygomatic arch with soft tissue component extending to infratemporal fossa and orbit. A fine needle aspirate from the temporal region swelling showed features of a plasmacytoma, and subsequent workup confirmed the presence of systemic disease. A final diagnosis of multiple myeloma with orbital involvement at presentation was made. CONCLUSION: Present case describes the extremely rare presentation of multiple myeloma with orbital involvement and highlights the utility of cytology in such lesions. Fine needle aspiration diagnosis of plasmacytoma at extramedullary sites offers an opportunity for non-invasive verification of systemic involvement, and thus plays a major role in early diagnosis and management of these patients.

Journal Article↗

Gauge freedom in orbital mechanics.

Both orbital and attitude dynamics employ the method of variation of parameters. In a non-perturbed setting, the coordinates (or the Euler angles) are expressed as functions of the time and six adjustable constants called elements. Under disturbance, each such expression becomes ansatz, the "constants" being endowed with time dependence. The perturbed velocity (linear or angular) consists of a partial time derivative and a convective term containing time derivatives of the "constants." It can be shown that this construction leaves one with a freedom to impose three arbitrary conditions on the "constants" and/or their derivatives. Out of convenience, the Lagrange constraint is often imposed. It nullifies the convective term and thereby guarantees that under perturbation the functional dependence of the velocity upon the time and "constants" stays the same as in the undisturbed case. "Constants" obeying this condition are called osculating elements. The "constants" chosen to be canonical, are called Delaunay elements, in the orbital case, or Andoyer elements, in the spin case. (Because some of the Andoyer elements are time dependent, even in the free-spin case, the role of "constants" is played by the initial values of these elements.) The Andoyer and Delaunay sets of elements share a feature not readily apparent: in certain cases the standard equations render these elements non-osculating. In orbital mechanics, elements calculated via the standard planetary equations turn out to be non-osculating when perturbations depend on velocities. To keep elements osculating under such perturbations, the equations must be amended with additional terms that are not parts of the disturbing function (Efroimsky and Goldreich 2003, 2004). For the Kepler elements, this merely complicates the equations. In the case of Delaunay parameterization, these extra terms not only complicate the equations, but also destroy their canonicity. So under velocity-dependent disturbances, osculation and canonicity are incompatible. Similarly, in spin dynamics the Andoyer elements turn out to be non-osculating under angular-velocity-dependent perturbation (a switch to a noninertial frame being one such case). Amendment of the dynamical equations only with extra terms in the Hamiltonian makes the equations render nonosculating Andoyer elements. To make them osculating, more terms must enter the equations (and the equations will no longer be canonical). It is often convenient to deliberately deviate from osculation by substituting the Lagrange constraint with an arbitrary condition that gives birth to a family of nonosculating elements. The freedom in choosing this condition is analogous to the gauge freedom. Calculations in nonosculating variables are mathematically valid and sometimes highly advantageous, but their physical interpretation is nontrivial. For example, nonosculating orbital elements parameterize instantaneous conics not tangent to the orbit, so the nonosculating inclination will be different from the real inclination of the physical orbit. We present examples of situations in which ignorance of the gauge freedom (and of the unwanted loss of osculation) leads to oversights.

Journal Article↗

Cell-mediated or humoral immunity in Graves' ophthalmopathy? Profiles of T-cell cytokines amplified by polymerase chain reaction from orbital tissue.

Whether Graves' ophthalmopathy is the results of a cell-mediated or humoral autoimmune response is controversial. T-Lymphocytes that regulate these two mechanisms, Th1 and Th2, respectively, are characterized by the profile of cytokines that they secrete. We, therefore, investigated the spectrum of T-lymphocyte cytokines expressed in Graves' orbital tissue by means of the polymerase chain reaction using reverse transcribed mRNA as template. From three Graves' thyroid tissues (positive controls), we obtained DNA products of the predicted size for the Th1 cytokines interferon-gamma (IFN gamma) and interleukin-2 (IL-2) as well as for Th2 cytokines IL-4 and IL-5. A signal for IL-10 (Th1 and Th2) was also detected. No cytokine signals were observed in peripheral blood (negative control). Despite the presence of T-cells (CD3 delta marker) in the orbital connective tissue/fat of all five patients studied as well as in orbital muscle from one of these patients, IFN gamma reverse transcribed mRNA was notably absent from these tissues. In contrast, IL-2, IL-5, and IL-10 cDNA was present in orbital tissues from one or more patients. Of particular importance, an IL-4 signal was detected in orbital connective tissue/fat of patients 6 and 7 as well as in muscle of patient 7. The balance between IL-4 and IFN gamma determines whether an immune response is predominantly humoral or cell mediated. Our finding of IL-4, but not IFN gamma, mRNA expression in orbital tissue supports a role, at least in some patients, for humoral autoimmunity in Graves' ophthalmopathy.

Aged↗

Effect of tumor necrosis factor-alpha, interferon-gamma, and transforming growth factor-beta on adipogenesis and expression of thyrotropin receptor in human orbital preadipocyte fibroblasts.

Graves' ophthalmopathy (GO) is an orbital autoimmune disease that is closely associated with Graves' hyperthyroidism. Examination of retroorbital tissues in GO reveals an accumulation of glycosaminoglycans, increased fat volume, lymphocytic infiltration, and the presence of several inflammatory cytokines. A subpopulation of human orbital fibroblasts can be differentiated in vitro into cells with the morphologic features of adipocytes. We demonstrated recently that these differentiated cultures show increased expression of functional TSH receptor (TSHr). To determine whether the presence of inflammatory cytokines might impact adipogenesis or TSHr expression in these cultures, we treated orbital fibroblasts from normal individuals or GO patients with tumor necrosis factor-alpha (TNF-alpha), interferon-gamma (IFN-gamma), or transforming growth factor-beta. We found that each of these cytokines inhibits TSH-dependent cAMP production and TSHr gene expression, and that TNF-alpha and IFN-gamma also inhibit morphological adipocyte differentiation. When cytokines were added after differentiation, the inhibition was less pronounced. Our results suggest that TNF-alpha, IFN-gamma, and transforming growth factor-beta may act within the orbit in GO to modulate expression of the putative orbital autoantigen, TSHr. In addition, the former two cytokines may play a role in determining the extent to which the volume of the orbital adipose tissue increases in this condition.

Adipocytes↗

Cytogenetic analysis of rare orbital tumors: further evidence for diagnostic implication.

INTRODUCTION. The pathologic diagnosis, and hence the management, of rare tumors of the orbit can represent a challenge. An increasing number of tumors have been shown to display specific chromosomal abnormalities detectable by cytogenetic analysis. MATERIALS AND METHODS. Two examples of rare primary orbital tumors are presented in which the correct pathologic diagnosis was either established or confirmed by cytogenetic analysis. Small pieces of the tumor were obtained at the time of biopsy and placed immediately, in a sterile fashion, in fresh culture medium. The cells were Giemsa stained and processed for chromosome analysis. RESULTS. In the first case, a 12-year-old boy was diagnosed with a sino-orbital mass after sustaining minor trauma. On biopsy, the pathologic examination was at first consistent with a Burkitt-like lymphoma, until cytogenetic analysis showed a t(8;21)(q22;q22) translocation, specific for granulocytic sarcoma, which corresponds to the localized solid form of acute myeloblastic leukemia. Consequently, proper chemotherapy was re-oriented and remission was achieved. In the second case, a 2-year-old boy presented with a well-vascularized orbital tumor. The histopathologic diagnosis of alveolar soft-part sarcoma of the orbit was confirmed by the finding of a specific t(X;17)(p11;q25) translocation. After two unsuccessful courses of chemotherapy, wide excision surgery with primary reconstruction brought remission. CONCLUSIONS. Cytogenetic analysis should be considered in the diagnosis of any orbital tumor which is suspected of malignancy.

Journal Article↗

Orbital cellulitis with gas.

Orbital cellulitis due to presumed gas-producing organisms has been associated with poor visual prognosis. We report successful visual recovery in a 14-year-old boy with orbital cellulitis and gas in the orbit on CT scan. The patient was treated with intravenous antibiotics and prompt orbital decompression. Pus from the sinus aspirate and orbital drain grew H. influenzae and Gram-negative bacilli. Repeat orbital surgery with drainage of residual abscess was performed and the patient made a complete recovery.

Journal Article↗

[Internal orbital decompression in uncompensated edematous exophthalmos].

The efficiency of internal orbital decompression was evaluated in uncompensated edematous exophthalmos (EE). Twenty-two patients aged 17-65 years who had EE (30 orbits) were followed up. EE in a subcompensation and decompensation stage occurred in 12 (17 orbits) and 10 (13 orbits) patients, respectively. When glucocorticoid therapy was ineffective, internal orbital decompression was made in order to preserve visual functions. Surgery was performed via transconjunctival approach (Brovkina, 2004). After surgery, exophthalmos diminished by an average of 4.6 and 5.6 mm in a subcompensation and decompensation stage, respectively. There was a substantial reduction in periorbital tissue edema, in conjunctival changes, corneal opacity, and optical neuropathy to the extent of complete regression. Internal orbital decompression is effective in uncompensated forms of EE, as appeared as a significant alleviation of its clinical symptoms and as preserved or increased baseline visual acuity.

Adolescent↗

Sarcoidosis with orbital tumor outside the lacrimal gland: initial manifestation in 2 elderly white women.

Two elderly white women (aged 72 and 87 years) were first seen with painless, unilateral orbital swelling. Orbital scanning revealed masses infiltrating the soft tissue around the eye. Biopsy results showed nodular, noncaseating granulomas consistent with sarcoidosis. One patient's workup revealed systemic manifestations of sarcoidosis at the time of examination with hilar lymphadenopathy noted on gallium scan; the other refused a complete systemic workup. The orbital tumors resolved with systemic prednisone therapy. To our knowledge, our 87-year-old patient is the oldest to be seen with orbital sarcoidosis. These 2 patients demonstrate that this diagnosis must be considered with orbital tumors in the elderly and in unusual locations, such as these which occurred outside the lacrimal gland.

Aged↗

A combined approach for the diagnosis of orbital disease. Computed tomography and standardized A-scan echography.

Twenty patients with orbital disease were studied by both computed tomography (CT scan) and standardized A-scan echography (ultrasonography). The CT scan was distinctly abnormal in 15 cases: 11/11 tumors were identified; a large wooden foreign body was identified; and nonspecific abnormal radiodensities were shown in three additional casses. Standardized A-scan echography, however, was capable of demonstrating the abnormality in all 20: in nine orbital tumors, a preoperative histologic diagnosis was attempted and proven accurate in all nine (in two no histologic disgnosis was attempted); and nontumor soft tissue abnormalities were equally readily classified. The overall diagnostic capability, therefore, in our series is 19/20 with a tissue diagnosis achieved on echographic bases in 17/20. (One case is excluded from this analysis as unexplained unilateral papilledema has been the only abnormality found and orbital abnormalities per se have not been proven.) We believe the roles of these two valuable diagnostic modalities to be complementary, not mutually exclusive, and conclude thet this combined radiologic and echographic approach to orbital abnormalities is essential to the proper evaluation of orbital disease.

Adolescent↗

Lateral orbitotomy without removal of the lateral orbital rim.

Lateral orbitotomy is used for the removal of orbital tumors and for orbital decompression. Most surgeons make saw cuts through the lateral orbital rim and remove and rewire the bone. This procedure is time-consuming and requires repair of the lateral canthal structures. We describe a technique using an air-driven "acorn-tipped" bur that removes the posterolateral lip of the frontal process of the zygomatic bone and effectively straightens the external surface of the lateral orbital wall. This permits removal of the bone without serious injury to the periorbita. The technique creates a trapezoidal orbitotomy measuring approximately 20 mm anteroposterior, 25 mm at the anterior vertical base, and 6 mm at the posterior base. The orbital soft tissues can thus be safely exposed without removal of the lateral rim. We operated on one patient with cavernous hemangioma (27 X 21 X 19 mm) and three patients with bilateral Graves' ophthalmopathy. We discuss anatomic considerations for the prevention of complications, including injury to the frontotemporal branches of the facial nerve, injury to the superior head of the lateral pterygoid muscle, and inadvertent penetration of the dura.

Dissection↗

The osseointegration technique for the rehabilitation of the exenterated orbit.

Osseointegrated implants can be used successfully to support maxillofacial prostheses. Six patients (aged 37 to 80 years; average age, 68 years) underwent orbital exenteration for eyelid neoplasms infiltrating into the orbit. Each patient underwent a two-stage osseointegration procedure in preparation for fitting an orbital prosthesis. In the first stage, three or four bone-anchored fixtures were placed into the bony orbital rim. Skin penetration and abutment placement were performed in the second-stage operation, performed 3 to 6 months later. Successful osseointegration was achieved in 17 (94.4%) of 18 fixtures in five nonirradiated patients. All five patients were successfully fitted with an implant-retained prosthesis. One patient who underwent irradiation lost all four fixtures that had been placed. This patient chose to wear a black patch rather than a conventional prosthesis held in with adhesive. Average follow-up was 16 months for the five patients who were successfully fitted with orbital prostheses (range, 6 to 30 months).

Adult↗

Endoscopic transantral orbital floor repair with antral bone grafts.

OBJECTIVE: To evaluate the endoscopic transantral insertion of antral bone grafts into the orbit for repair of orbital floor defects. DESIGN: A retrospective analysis with a mean follow-up of 5.3 months. PATIENTS: Eleven patients who underwent surgical repair of orbital floor fractures. SETTING: Municipal hospital. MAIN OUTCOME MEASURES: Preoperative and postoperative Hess screen tests and the presence of diplopia, enophthalmos, donor site complications, cosmetic deformity, infection, and graft extrusion. RESULTS: Subjectively, 3 patients with diplopia had complete resolution of their symptoms after surgery, and 8 patients had improvement of their symptoms. Objectively, 11 patients had significant improvement in the postoperative Hess area ratio compared with the preoperative Hess area ratio. In 1 patient with a floor defect measuring 2.5 cm, enophthalmos existed after surgery, but reoperation was not performed in this case because diplopia was improved. There were no donor site complications, cosmetic deformity, infection, or graft extrusion. CONCLUSIONS: The endoscopic transantral insertion of antral bone grafts through the floor defect into the orbit is an effective technique that prevents injury to the lower eyelid, carries minimal donor site morbidity, and provides an optimal support function for the globe. It merits consideration in cases of orbital defects less than 2 cm in diameter.

Adolescent↗

Fine-needle aspiration for the diagnosis of orbital hematolymphoid lesions.

Ocular and periocular hematolymphoid diseases are a diverse group of lesions affecting various soft tissue structures within the orbital cavity. Lymphoid proliferations in particular are among the most commonly diagnosed entities in orbital pathology. When noninvasive techniques fail to confirm or rule out the suspicion of orbital neoplasia, fine-needle aspiration (FNA) may be of use in establishing a diagnosis in a reliable, timely, cost-effective and safe manner. From 1986 to 1999, 79 orbital/ocular needle aspiration biopsies were conducted by staff ophthalmologists at Allegheny General Hospital. Slides from these cases and corresponding reports were pulled from the cytology files and grouped into the two broad categories of hematolymphoid and other. Specimens came from patients ranging in age from 14 to 88 years (mean, 64 years) with eight patients having known histories of hematolymphoid disorders. Immunocytochemical (ICC) studies were performed in 33% of the cases (14/43). Review of the diagnoses for the 79 aspiration specimens revealed 30 cases diagnosed as lymphoma/atypical lymphocytic infiltrate, cases diagnosed as inflammation or abscess, three cases diagnosed as plasmacytoma, three cases called suboptimal with scant inflammatory cells, and one case of Langerhans' cell histiocytosis. Hematolymphoid diagnoses accounted for 54% (43/79) of all diagnoses. Histologic correlation was available in 33% (14/43) of the cases (nine cases diagnosed as cytologically atypical/malignant and five cases called cytologically benign/suboptimal) with 100% correlation. Hematolymphoid lesions of the orbit are readily diagnosed by FNA. Because many hematolymphoid malignancies are treated as systemic or multiorgan system diseases and because ocular lymphomas may also involve the central nervous system, nonsurgical attempts at diagnosis have the potential to spare the patient procedural morbidity which may be associated with open biopsy. Our experience indicates that the combination of FNA, judicious use of immunocytochemical studies, and correlation with pertinent clinical information and imaging studies allows for reliable and effective classification and diagnosis of orbital hematolymphoid lesions.

Adult↗

Orbital diagnosis.

Accurate localization and diagnosis of orbital lesions is necessary to select the appropriate treatment. A systematic method of evaluating a patient with orbital disease is presented. The most common orbital lesions among children and adults are listed, and abnormalities that mimic exophthalmos are described. The tests that are most useful in evaluating orbital disease are described in detail. Several case reports illustrate the value of ultrasonography and three-dimensional computed tomography in the localization and diagnosis of space-occupying lesions of the orbit. Special tissue-processing techniques can be performed on some tumors to aid in establishing a diagnosis and in planning treatment.

Adult↗