full-thickness skin grafts are quite viable and effective in the periocular region even when the area has previously been treated with high-dose radiation therapy.

20.3 Entropion

Entropion is much less common than ectropion in cancer patients. As in the general population, the most common form of entropion in cancer patients is caused by lower eyelid laxity and disinsertion of the lower eyelid retractors. Cancer patients can also have cicatricial entropion as a complication of eyelid reconstruction in the periocular region or as a result of conjunctival scarring after surgery or radiation therapy. An eyelid-shortening procedure such as the lateral tarsal strip procedure is the typical corrective procedure.

20.4 Ptosis

The most common cause of ptosis in cancer patients is surgery. Postsurgical ptosis can be due to extensive resection of the upper eyelid or damage to the levator complex during surgery (Fig. 20.3).

Fig. 20.3 Iatrogenic ptosis of the upper eyelid due to damage to the levator complex during resection of a squamous cell carcinoma of the forehead and brow area. There is also a component of mechanical ptosis due to the free flap in the forehead

Malignancies can cause a neurogenic ptosis in the form of Horner’s syndrome. Tumors in the lateral medulla can affect the first-order neuron. Apical lung cancers, Pancoast tumors, and head and neck cancers necessitating extensive neck dissection can cause a second-order Horner’s syndrome. In children, malignancy can produce an acquired Horner’s syndrome. In a study of 56 pediatric patients with Horner’s syndrome, 23% of the cases were due to neoplasm, most commonly neuroblastoma [8]. Loss of sympathetic stimulation of Mueller’s muscle typically results in 1–2 mm of ptosis. Patients also have the other classic findings in Horner’s syndrome, including elevation of the lower eyelid, miosis, anhidrosis, conjunctival injection, and a drop in intraocular pressure. If the ptosis is causing visual compromise or is cosmetically unacceptable, repair using the posterior müllerectomy technique or a Fasanella–Servat procedure (tarsoconjunctival müllerectomy) would be adequate.

Compressive neoplasms, particularly skull base tumors, can be a cause of thirdnerve palsy and resultant upper eyelid ptosis. Patients with this type of ptosis would be expected to have other oculomotor disturbances as well as a dilated pupil.

Lambert–Eaton myasthenic syndrome is a cause of ptosis in some cancer patients. It is a paraneoplastic syndrome, seen most commonly in small cell lung cancer, that can cause ptosis as well as proximal muscle weakness and autonomic dysfunction. In some cases, these symptoms precede the diagnosis of the underlying malignancy. The syndrome is caused by immunoglobulins directed against presynaptic calcium channels.

Plexiform neurofibromas can cause mechanical ptosis. These lesions typically present with an S-shaped deformity of the upper eyelid (please see Chapter 2).

20.5 Eyelid Retraction

In cases of massive proptosis due to large orbital tumors, the eyelid may not adequately cover the surface of the globe (Fig. 20.4). In this situation, there are often severe symptoms of exposure. Depending on the tumor type, treatment with chemotherapy, local radiation therapy, or surgical resection may allow the globe to return to the normal position in the orbit.

20.6 Periorbital Edema Secondary to Imatinib Mesylate

Imatinib mesylate (Gleevec) is a tyrosine kinase receptor inhibitor used in the treatment of certain cases of chronic myelogenous leukemia and gastrointestinal stromal tumor. In a phase I study, imatinib mesylate was noted to cause periorbital edema in 30% of patients [9]. In some cases, the edema is so severe that visual compromise develops and surgical debulking is necessary (Fig. 20.5) [10]. It has been shown that the cells in the periocular dermis express tyrosine kinase

Fig. 20.4 Metastatic Ewing sarcoma causing massive proptosis, upper and lower eyelid retraction, and exposure keratopathy. From Savar A, Trent J, Al-Zubidi N, et al. Efficacy of adjuvant and neoadjuvant therapies for adult orbital sarcomas. Ophthal Plast Reconstr Surg 2010;26(3):185–189. Reprinted with permission

Fig. 20.5 Severe periorbital edema and lower eyelid festoons caused by imatinib mesylate in a patient with chronic myelogenous leukemia. From Esmaeli B, Diba R, Ahmadi MA, et al. Periorbital oedema and apiphora as ocular side effects of imatinib mesylate (Gleevec) [letter]. Eye 2004;18:760–762

receptors targeted by imatinib, including the platelet-derived growth factor receptor. This receptor is known to be involved in the regulation of tissue fluid, which may explain the propensity for edema formation in this area with imatinib treatment [10, 11].

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