Dr. Lucarelli is a Professor in the Department of Ophthalmology and Visual Sciences, University of Wisconsin–Madison, where he is Director of the Oculoplastics Service. Dr. Lucarelli is recognized as a leader within his field which specializes in disorders of the eyelids, lacrimal system, orbit, and related facial structures. His research interests center on surgical techniques and anatomic studies of the periocular structures. Dr. Lucarelli has a special interest in thyroid eye disease (Graves' orbitopathy) and serves on the International Thyroid Eye Disease Study Board (ITEDS).
Necrotizing myositis in a rectus muscle arising in the setting of long-standing Langerhans cell histiocystosis and recent dabrafenib treatment.
Am J Ophthalmol Case Rep. 2020 Dec;20:100868
Authors: van Landingham SW, Puccetti D, Potter H, Gamm D, Diamond EL, Lucarelli MJ
Purpose: to describe an unusual case of necrotizing myositis in a rectus muscle, possibly related to BRAF inhibitor therapy.
Observations: An 18-year old man with neurodegenerative Langerhans cell histiocytosis (LCH), recently started on the BRAF inhibitor dabrafenib, presented with right eye pain. Magnetic resonance imaging (MRI) orbits revealed a rectus muscle mass concerning for LCH recurrence or malignancy. Dabrafenib was stopped, and incisional biopsy of the mass was performed. The mass was absent on post-operative MRI, so no further treatment was pursued. Histopathologic evaluation was initially concerning for sarcoma, but on further analysis, appeared more consistent with necrotizing myositis. The mass did not recur, nor did the patient develop other signs or symptoms concerning for myositis or malignancy over a 24-month follow-up period.
Conclusions: Necrotizing myositis has not been previously described in a rectus muscle or with BRAF inhibitor use, though myalgias and malignancies are established side effects. Necrotizing myositis may masquerade as sarcoma and should be on the differential diagnosis for a new mass in the setting of dabrafenib therapy.
PMID: 32875153 [PubMed]
Physical therapy for facial nerve palsy: applications for the physician.
Curr Opin Ophthalmol. 2018 Jul 09;:
Authors: van Landingham SW, Diels J, Lucarelli MJ
PURPOSE OF REVIEW: The aim of this study was to describe the current state of physical therapy for facial nerve palsy, the evidence basis for these interventions and how therapy can be integrated with other medical and surgical interventions for facial nerve palsy, as it applies to ophthalmologists, oculoplastic surgeons and other specialists.
RECENT FINDINGS: Many studies indicate that physical therapy is effective for the rehabilitation of patients with facial nerve palsy and can be used synergistically with interventions administered by physicians, such as targeted botulinum toxin injections. The field is limited by a relative paucity of high-quality randomized controlled trials. Alternative therapies including Brief Electrical Stimulation continue to be studied; however, they lack a scientific rationale and, anecdotally, appear to cause more problems in cases of incomplete facial nerve recovery.
SUMMARY: Physical therapy, specifically neuromuscular retraining, is a useful intervention for treating facial nerve palsy. Care for these patients is best delivered in a multidisciplinary setting in which physical therapy and medical or surgical interventions can be closely integrated. Further study aimed at standardizing physical therapy and optimizing the integration of this with other treatments for facial nerve palsy are needed.
PMID: 29994853 [PubMed - as supplied by publisher]
Traumatic orbital encephalocele: Presentation and imaging.
Orbit. 2016 Apr;35(2):72-7
Authors: Wei LA, Kennedy TA, Paul S, Wells TS, Griepentrog GJ, Lucarelli MJ
OBJECTIVE: Traumatic orbital encephalocele is a rare but severe complication of orbital roof fractures. We describe 3 cases of orbital encephalocele due to trauma in children.
METHODS: Retrospective case series from the University of Wisconsin - Madison and Medical College of Wisconsin.
RESULTS: Three cases of traumatic orbital encephalocele in pediatric patients were found. The mechanism of injury was motor vehicle accident in 2 patients and accidental self-inflicted gunshot wound in 1 patient. All 3 patients sustained orbital roof fractures (4 mm to 19 mm in width) and frontal lobe contusions with high intracranial pressure. A key finding in all 3 cases was progression of proptosis and globe displacement 4 to 11 days after initial injury. On initial CT, all were diagnosed with extraconal hemorrhage adjacent to the roof fractures, with subsequent enlargement of the mass and eventual diagnosis of encephalocele.
CONCLUSION: Orbital encephalocele is a severe and sight-threatening complication of orbital roof fractures. Post-traumatic orbital encephalocele can be challenging to diagnose on CT as patients with this condition often have associated orbital and intracranial hematoma, which can be difficult to distinguish from herniated brain tissue. When there is a high index of suspicion for encephalocele, an MRI of the orbits and brain with contrast should be obtained for additional characterization. Imaging signs that should raise suspicion for traumatic orbital encephalocele include an enlarging heterogeneous orbital mass in conjunction with a roof fracture and/or widening fracture segments.
PMID: 26905453 [PubMed - in process]
Nasolacrimal System Fractures: A Description of Radiologic Findings and Associated Outcomes.
Ann Plast Surg. 2015 Mar 26;
Authors: Garg RK, Hartman MJ, Lucarelli MJ, Leverson G, Afifi AM, Gentry LR
BACKGROUND: Fractures of the bony nasolacrimal system (NLS), including the lacrimal sac fossa and nasolacrimal canal, have not been comprehensively described in patients with facial trauma. Characterization of these injuries may help facial trauma surgeons better predict which patients will develop lacrimal outflow obstruction symptoms including epiphora and dacryocystitis and who may eventually need lacrimal surgery.
METHODS: CT images for all patients seen at the University of Wisconsin Hospital and Clinics for craniofacial trauma were reviewed from January 2001 to December 2005. Patients were included if they had a NLS fracture and at least 1 year of follow-up. Fracture patterns were described and correlated with clinical outcomes documented in the medical record. Outcomes, including the development of epiphora or dacryocystitis and the need for lacrimal surgery, were analyzed using Fisher exact test.
RESULTS: We identified 104 patients with NLS fractures among 1980 patients with craniofacial trauma who had at least 1 year of follow-up. Eleven patients (10.6%) developed epiphora or dacryocystitis, and 2 patients (1.9%) required dacryocystorhinostomy (DCR). Ten radiographic injury patterns were characterized. Avulsion of the lacrimal crest, bone fragment in the lacrimal sac fossa or duct, duct compression greater than 50%, and nasomaxillary buttress displacement were significantly associated with the development of epiphora or dacryocystitis (P < 0.05). Nasomaxillary buttress displacement was significantly associated with the eventual need for DCR (P = 0.03).
CONCLUSIONS: Patients with radiographic evidence of NLS fracture have an approximately 10% risk of developing epiphora or dacryocystitis. We describe 5 NLS fracture findings that are significantly associated with the development of lacrimal outflow obstruction. The presence of nasomaxillary buttress fracture and displacement suggests a significantly higher risk of eventually needing lacrimal surgery.
PMID: 25815677 [PubMed - as supplied by publisher]
Severe Oculofacial Sequelae of Cutaneous Blastomyces dermatitidis.
Ophthal Plast Reconstr Surg. 2014 Aug 5;
Authors: Schmutz JS, Ramey NA, Gauthier GM, Lucarelli MJ
This study reports a case of Blastomyces dermatitidis soft tissue infection resulting in a disfiguring lower eyelid ectropion from cicatricial and postinflammatory cutaneous changes. Primary treatment included intravenous amphotericin B followed by long-term oral itraconazole, which resulted in complete remission of the disease without debridement, after which cicatricial ectropion was repaired surgically with scar release, full-thickness skin graft, and temporary Frost tarsorraphy. Cutaneous blastomycosis may cause severe oculofacial sequelae, ranging from eyelid ectropion to widespread facial cicatrix, and may mimic other more common infectious processes, in addition to malignancy. Recommended antifungal therapy includes induction with intravenous amphotericin B and a long course of oral antifungals, preferably coordinated in conjunction with an infectious disease specialist. Ectropion repair should be delayed until the inflammatory response has completely healed. If the ocular surface is compromised or nearby ocular structures are threatened, primary debridement and repair may be indicated.
PMID: 25098446 [PubMed - as supplied by publisher]
Orbital osteoma: clinical features and management options.
Ophthal Plast Reconstr Surg. 2014 Mar-Apr;30(2):168-74
Authors: Wei LA, Ramey NA, Durairaj VD, Ramakrishnan VR, Cruz AV, Dolman PJ, Lucarelli MJ
PURPOSE: This study reviews the clinical presentation and management of 11 cases of sino-orbital osteoma.
METHODS: The medical records of patients with primary (originating from orbital bone) and secondary (originating from the paranasal sinuses) orbital osteoma from the academic practices of 4 surgeons (A.V.C., M.J.L., P.J.D., V.D.D.) were reviewed for clinical presentation and course, pathologic study, and radiologic reports. A Medline search of English-language literature on orbital osteomas was conducted for comparison with these findings.
RESULTS: Eleven cases of primary (1) and secondary (10) orbital osteoma were reviewed, with a mean follow up of 16 months. Seven patients were women. Ages ranged from 15-68 years, with a median of 40 years. Presenting complaints included slowly progressive globe displacement, palpable bony nodule, pain, and diplopia. Surgery was performed in 10 cases. Surgical approach varied according to location and size of each lesion and was performed in combination with otolaryngology and neurosurgery services as needed. Reconstruction included sculpting osteomatous bone to natural orbital contours, repair of orbital wall defects with implants, and obliteration of frontal sinus. Lesions demonstrated mixed compact, cancellous, and fibrous histologic subtypes.
CONCLUSIONS: Osteomas are the most common tumor of the paranasal sinuses (noted in up to 3% of coronal CT images), but secondary extension in or primary involvement of the orbit is rare. A variety of surgical approaches led to successful outcomes in this series. Complete surgical removal is not always necessary, and partial sculpting may relieve symptoms and cause less surgical morbidity in selected cases.
PMID: 24614547 [PubMed - indexed for MEDLINE]
Tumors masquerading in patients with thyroid eye disease.
Orbit. 2013 Aug;32(4):260-2
Authors: Griepentrog GJ, Burkat CN, Kikkawa DO, Lucarelli MJ
Thyroid eye disease (TED) is the most common cause of proptosis in adults. The external manifestations of TED are characteristic and the diagnosis is typically made without imaging. Although there are multiple descriptions of primary and secondary orbital tumors initially mistaken for TED in the literature, there are limited reports detailing the findings of patients with long-standing TED whom developed an orbital tumor at a later date. Herein, we present a 6-year retrospective multi-center report of three patients with long-standing TED who developed an initially unsuspected orbital or cavernous sinus tumor.
PMID: 23662589 [PubMed - indexed for MEDLINE]
Modified full-thickness anterior blepharotomy for upper eyelid retraction in children.
J AAPOS. 2013 Apr;17(2):223-4
Authors: Stewart KJ, Griepentrog GJ, Lucarelli MJ
Graded full-thickness anterior blepharotomy has been used to treat eyelid retraction in adult patients with thyroid eye disease. We report 2 children diagnosed with upper eyelid retraction who underwent a modified full-thickness anterior blepharotomy. In both cases, symptoms resolved and cosmetically acceptable outcomes were achieved.
PMID: 23522943 [PubMed - indexed for MEDLINE]
Anatomical position of hyaluronic Acid gel following injection to the infraorbital hollows.
Ophthal Plast Reconstr Surg. 2013 Jan-Feb;29(1):35-9
Authors: Griepentrog GJ, Lemke BN, Burkat CN, Rose JG, Lucarelli MJ
PURPOSE: To examine with histology the anatomical location of hyaluronic acid gel injected to the infraorbital hollows of cadaver specimens.
METHODS: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the infraorbital hollows. Following tissue fixation, full-thickness soft tissue sections were obtained along the medial, central, and lateral lower eyelid/midface of each specimen. Histologic examination of the anatomical location of hyaluronic acid gel was performed using hematoxylin and eosin and Hale colloidal iron stains.
RESULTS: Histologic examination of the central and lateral lower eyelid/midface sections revealed a significant portion of hyaluronic acid gel in either a postorbicularis or a subcutaneous plane in 8 of 10 sections. Only 2 sections displayed hyaluronic acid gel solely within a preperiosteal plane. The medial sections revealed hyaluronic acid gel resting in either a preperiosteal or an intraorbicularis plane. Soft tissue structures such as deep fat compartment septa and the orbicularis oculi muscle appeared to play a significant role in influencing the resting position of hyaluronic acid gel.
CONCLUSIONS: In most specimens, the location of a significant portion of hyaluronic acid gel following injection to the infraorbital hollows differed from the intended injection plane. Soft tissue structures including fat compartment septa and the orbicularis oculi muscle appear to influence the resting position of hyaluronic acid gel. Careful attention should be used to avoid overfilling the thin soft tissue layers of the medial infraorbital hollows or tear trough.
PMID: 23299806 [PubMed - indexed for MEDLINE]
Anatomical position of hyaluronic acid gel following injection to the eyebrow.
Ophthal Plast Reconstr Surg. 2013 Sep-Oct;29(5):364-6
Authors: Griepentrog GJ, Lucarelli MJ
PURPOSE: To examine with histology the anatomical location of hyaluronic acid gel injected to the eyebrow of cadaver specimens.
METHODS: The authors dissected 5 fresh hemifacial cadaver specimens following preperiosteal injection of hyaluronic acid gel to the eyebrow. Following tissue fixation, full-thickness soft-tissue sections were obtained followed by histologic examination.
RESULTS: Histologic examination revealed the location of hyaluronic acid gel at the intended preperiosteal plane in all 5 specimens. Very dense retro-orbicularis oculi fat septa appeared to limit the anterior displacement of filler in each specimen.
CONCLUSIONS: This study provides a greater understanding of the anatomical barriers and boundaries that help to determine, in part, the anatomical position of hyaluronic acid gel when injected to the preperiosteal eyebrow. The high degree of histologically confirmed consistency of product location of eyebrow injections noted in this study stands in contrast to the variability of position of gel injected in the infraorbital hollows.
PMID: 23880972 [PubMed - indexed for MEDLINE]
Clinical usefulness of orbital and facial Time-Resolved Imaging of Contrast KineticS (TRICKS) magnetic resonance angiography.
Ophthal Plast Reconstr Surg. 2012 Sep-Oct;28(5):361-8
Authors: Ramey NA, Lucarelli MJ, Gentry LR, Burkat CN
PURPOSE: The clinical usefulness of orbital and facial Time-Resolved Imaging of Contrast KineticS (TRICKS) MRI was assessed quantitatively and qualitatively.
METHODS: A retrospective chart review of the years 2001 to 2011 was conducted at the University of Wisconsin, Madison. Patients were selected based on tumor location (extracranial head and neck) and evaluation with TRICKS imaging at any stage of the clinical course. The TRICKS protocol presented in this article allows measurement of specific tumor characteristics including lesion morphology, vascular anatomy, flow dynamics within the lesion, rapidity and sequential nature of contrast enhancement, and lesion distensibility. Cases involving changes in diagnoses and/or management as a result of TRICKS interpretation are presented in detail.
RESULTS: The imaging records of 49 patients were reviewed. Most lesions were located in or around the orbit (32 lesions, 65%). Benign vascular tumors comprised the largest subcategory (32 lesions, 65%) in the cohort. Of the 20 cases with histopathological data, interpretation of MRI with TRICKS magnetic resonance angiography successfully predicted 17 (85%). Characteristic enhancement patterns for the most commonly encountered lesions are presented, in addition to a qualitative analysis of how TRICKS contributed to select cases. TRICKS helped clarify diagnosis and/or redirect management in 19 of the 49 cases in this series.
CONCLUSION: To the best of the authors' knowledge, this is the largest study to date of patients evaluated with TRICKS MRI/magnetic resonance angiography for orbital and facial tumors. MRI with TRICKS magnetic resonance angiography imaging protocol offers a minimally invasive, safe, and effective diagnostic instrument in selected patients with clinical diagnostic uncertainty and in those patients requiring high-resolution vascular mapping for management planning.
PMID: 22836799 [PubMed - indexed for MEDLINE]
Cosmetic use of botulinum toxin-a affects processing of emotional language.
Psychol Sci. 2010 Jul;21(7):895-900
Authors: Havas DA, Glenberg AM, Gutowski KA, Lucarelli MJ, Davidson RJ
How does language reliably evoke emotion, as it does when people read a favorite novel or listen to a skilled orator? Recent evidence suggests that comprehension involves a mental simulation of sentence content that calls on the same neural systems used in literal action, perception, and emotion. In this study, we demonstrated that involuntary facial expression plays a causal role in the processing of emotional language. Subcutaneous injections of botulinum toxin-A (BTX) were used to temporarily paralyze the facial muscle used in frowning. We found that BTX selectively slowed the reading of sentences that described situations that normally require the paralyzed muscle for expressing the emotions evoked by the sentences. This finding demonstrates that peripheral feedback plays a role in language processing, supports facial-feedback theories of emotional cognition, and raises questions about the effects of BTX on cognition and emotional reactivity. We account for the role of facial feedback in language processing by considering neurophysiological mechanisms and reinforcement-learning theory.
PMID: 20548056 [PubMed - indexed for MEDLINE]