Idiopathic orbital inflammation with bone destruction and extension into the paranasal sinuses

Idiopathic orbital inflammation developed in the right orbit of a woman in her mid-thirties, causing tearing, photophobia, diplopia, altered depth perception, proptosis, and pain on eye movements. Computed tomography disclosed a mass involving the intraconal and extraconal nasal right orbit, extending to the orbital apex with anterior displacement of the globe, effacement of the medial rectus muscle, portions of the fat plane, and the superior oblique muscle, and bone destruction with extension of the mass through the orbital floor into the superior maxillary sinus and through the lamina papyracea into the ethmoid sinus. Orbital biopsy disclosed dense fibrous connective tissue with numerous lymphocytes and macrophages. Immunohistochemical stains supported a diagnosis of idiopathic inflammatory pseudotumor involving the orbit and sinus mucosa. Treatment with a prednisone taper and a retrobulbar injection of triamcinolone acetonide have relieved her symptoms and diminished her proptosis. This patient highlights the rare potential of idiopathic orbital inflammation to erode though bone into adjacent cranial structures.     

眶内壁爆裂性骨折眼外肌功能损伤性质的临床研究

目的探讨眶内壁爆裂性骨折患者眼外肌损伤性质等临床特征与骨折形态学特点的相关性。方法根据眶内壁爆裂性骨折的部位和形态学特点，对82例单纯眶内壁骨折进行CT亚型分类：Ⅰ型：整个筛骨纸板粉碎性骨折，筛窦为眶内软组织所填充，内直肌向内明显弯曲、移位；Ⅱ型：筛骨纸板局部骨折，筛窦基本完整，骨折片与眶壁之间形成夹角。内直肌周围软组织嵌顿于骨折区。观察两亚型间患者的眼外肌功能变化特点和相关临床特征。结果Ⅰ型眶内壁骨折的骨折位置偏后、面积较大，眼肌功能损伤性质以内直肌麻痹为主（14／20）；Ⅱ型眶内壁骨折的位置偏前，面积较小，眼肌功能损伤以内直肌运动受限为多见（27／38）。Ⅰ型眶内壁骨折患者眼球内陷发生率及内陷程度均明显高于Ⅱ型眶内壁骨折（z=-6．075，P〈0．05；t=3．365，P〈0．05）。而复视发生率明显低于Ⅱ型眶内壁骨折（Z=-2．187，P〈0．05）。结论眶内壁骨折患者眼外肌功能损伤改变等临床特征与骨折的形态学特点有关；眶内壁骨折CT影像学亚型分类具有临床实用价值。     

Characterization and Outcomes of Repeat Orbital Decompression for Thyroid-Associated Orbitopathy

Orbital decompression for thyroid-associated orbitopathy (TAO) is commonly performed for disfiguring proptosis, congestion, and optic neuropathy. Although one decompression typically achieves goals, a small percentage requires repeat decompression. We performed a 10-year retrospective chart review of all orbital decompressions for TAO at a single tertiary referral institution. Four-hundred and ninety-five orbits (330 patients) were decompressed for TAO, with 45 orbits (37 patients) requiring repeat decompression. We reviewed the repeat cases for indications, clinical activity scores, approach, walls decompressed, and outcomes. Nine percent of orbits required repeat decompression for proptosis (70%), optic neuropathy (25%) or congestion (45%). Sixty-four percent were for recurrence of disease, 36% were for suboptimal decompression. Three incisional approaches were used: lateral upper eyelid crease, inferior transconjunctival, and transcaruncular, with inferior transconjunctival being most common. Of the three walls removed, deep lateral, inferior, and medial, the deep lateral wall was most common (51%). A repeat lateral decompression was the most frequent pattern. Of 37 patients requiring repeat decompression, 40% had diplopia prior to repeat, and an additional 24% developed diplopia after the repeat. Whereas previous studies published by our group cited only 2.6% of deep lateral wall orbital decompressions leading to new-onset primary gaze diplopia, repeat orbital decompressions have a much higher rate of post-operative diplopia. The new onset primary gaze diplopia after repeat decompression group had a higher average preoperative CAS (3.3 vs. 2.4, p?p?=?0.04), more frequent medial wall decompressions (47% vs. 29%, p?=?0.33), and greater proptosis reduction (2.4 vs. 1.7?mm, p?=?0.24).     

Medial blow-out fracture: Symptoms and reconstruction of an unusual case

After a ski-accident a 13–year-old boy sustained contusion of the right eye with medial blow-out fracture. The lamina papyracea and a part of the orbital tissues were dislocated into the nasal cavity. Enophthalmos and restriction of the motility of the eye in all directions, except abduction, was the result. For reconstruction, reposition and fixation of the lamina papyracea with a free composite graft consisting of septum cartilage and mucosa (1.5 × 2 cm) was performed.     

Orbital Cellulitis and Subperiosteal Abscess: A 5-year Outcomes Analysis

Purpose: Orbital cellulitis and subperiosteal abscess (SPA) are historically associated with poor outcomes. We seek to characterize current associations with abscess formation, surgical failure and vision loss.

Methods: All cases of orbital cellulitis presenting to an affiliated hospital between April 2008 and 2013 were critically reviewed.

Results: Thirty patients met inclusion criteria. Average age was 28.7?±?24.4. The male to female ratio was 2:1. Abscesses were identified in 56.7% of patients. Adults were less likely than children to present with abscesses (28.6% vs. 81.3%, p?=?0.008). Of the other factors analyzed, only antibiotic use before admission (70.5% vs. 23.1%, p?=?0.03) and maximum restriction (?2.5?±?1.2 vs. ?0.9?±?0.7, p?=?0.008) were associated with SPA. Temperature at presentation (37.9?±?0.9 vs. 37.1?±?0.4, p?=?0.04), relative proptosis (5.8?±?3.3?mm vs. 2.1?±?1.1, p?=?0.002) and abscess volume (4.3?±?1.3?mm³ vs. 0.7?±?0.5?mm³, p?=?0.0004) were associated with progression to surgery. Reoperation was required in 26.7% of patients. Of these, two-thirds had combined superior/medial abscesses that re-accumulated after isolated endonasal surgery. Two of the 3 patients with profound vision loss had a dental etiology.

Conclusions: Only young age, prior antibiotics and degree of restriction predicted the presence of an abscess. Re-accumulation was more common than anticipated, and drainage of superior/medial abscesses by endoscopic surgery alone had the strongest association with surgical failure. Patients with odontogenic abscesses must be treated with particular caution.     

应用AO三维预成型钛网治疗眼眶骨折的临床研究

目的：：评价三维预成型钛网在单纯性眶壁骨折修复中的精确性和可行性。方法：本研究共包括47例单纯性眶壁骨折患者,骨折部位如下：内下壁联合骨折26例(55%),单纯眶内壁骨折12例(26%),单纯眶下壁骨折9例(19%)。对于眶下壁骨折,采用标准的经下睑结膜入路;而对于眶内壁骨折和内下壁联合骨折,则采用经泪阜、经下睑结膜联合入路,同时暂时切断下斜肌将两切口沟通。所有患者均充分暴露骨折边缘并还纳疝出的眶内组织后,根据术前CT测量的骨折缺损范围,选择对应型号的AO三维预成型钛网并进行适当的修剪和弯制后植入眶内,使用两颗钛钉将钛网固定于眶下缘。通过术后复查眼眶三维CT来评价植入钛网的精确性,通过对患者术前和术后的临床资料的对比来评价预成型钛网临床应用的可行性。结果：术后CT表明,所有患者的眼眶骨折在植入三维预成型钛网后均得到比较精确的解剖修复。所有患者在术中、术后均未出现严重的并发症,40例(87%)患者眼球内陷得以矫正,25例(86%)患者复视消失。结论：AO三维预成型钛网在解剖上可比较精确地修复眶壁骨折;在临床上,可以显著改善眼球内陷和复视。     

下睑缘入路治疗眶内下壁联合骨折

目的评价采用下睑缘切口治疗眶内、下壁联合骨折的效果。设计回顾性病例系列。研究对象18例眶内、下壁联合骨折的患者。方法所有患者均经下睑缘切口行眶壁骨折整复术,术中充分游离、保护泪囊,于眶内、下壁浅面植入复合羟基磷灰石人造骨片,术前、术后行双眶水平及冠状位CT、头面部三维cT检查并进行比较。主要指标临床症状及并发症。结果术后随访3～18个月,所有患者下睑皮肤瘢痕不明显,术后均未出现人造骨片排异或移位,无一例患者术后出现溢泪,复视、眼球内陷等症状均得到改善。结论单独采用下睑缘切口治疗眶内、下壁联合骨折是可行的,但仅适于眶下壁联合眶内壁下份骨折,尤其是伴发眶内、下壁隅角骨折的复合型骨折。     

American Uveitis Society Winter Symposium,January 1997

Abstract

Purpose: To investigate the association between smoking and prognosis of ocular Behçet disease.

Material/Methods: Medical records of 202 patients with Behçet uveitis were collected retrospectively. Patients were assigned to two groups according to smoking habits. In group I, 72 patients were current smokers. In group II, 130 were nonsmokers. The localization of uveitis, time to resolution of uveitis, time to recurrences, visual acuities, and presence of cystoid macular edema were compared between groups.

Results: The demographic characteristics were similar in both groups. Smoking was not associated with types of uveitis with OR of 1.01 (95% CI, 0.99–1.04; p?=?0.21) for anterior uveitis, 0.96 (95%CI, 0.90–1.02; p?=?0.18) for posterior uveitis, and 1.80 (95% CI, 0.75–2.77; p?=?0.24) for panuveitis. The average times to inflammation resolution were 48?±?10.1 days in group I and 51?±?14 days in group II (p?=?0.82). The average times to recurrence were 8.6?±?5 months for smokers and 9.1?±?7 months for nonsmokers (p?=?0.43). Patients with CME in groups were 18 (25%) and 42 (32.3%), respectively (p?=?0.08).

Conclusions: Our findings suggest that smoking does not have a negative effect on the clinical findings and prognosis of uveitis in Behçet disease.     

The Role of Tissue Resection Length in the Determination of Post-Operative Eyelid Position for Muller’s Muscle-Conjunctival Resection Surgery

Purpose: To investigate the relationships between pre-operative marginal reflex distance (MRD), tissue resection length, phenylephrine response, and change in MRD with surgery for a cohort of individuals undergoing Muller’s muscle conjunctival resection (MMCR) surgery.

Methods: All cases of MMCR surgery performed over a 13-year period at a single institution were screened for entry. Individuals with adequate photographic documentation and follow up were included. Patients with previous or concurrent upper eyelid, orbital or eyebrow disease of surgery were excluded. Marginal reflex distance (MRD) was calculated based on photographs utilizing public domain software. Data was plotted for inspection and appropriate statistical tests were performed.

Results: During the study period 198 eyes fit criteria for analysis. A loose association between tissue resection length and change in MRD with surgery was found (r?=?0.176, p?p?=?0.367). There was a strong association between MRD change with surgery and pre-operative MRD (r?=?0.498, p?r?=??0.441, p?2?mm and pre-operative MRD as variables revealed a model with pre-operative MRD as the only significant predictor (p?Conclusion: Tissue resection length and phenylephrine response play small roles relative to pre-operative MRD in the determination of change in MRD with MMCR surgery.     

Incarceration of the Inferior Oblique Muscle Branch of the Oculomotor Nerve in Two Cases of Orbital Floor Trapdoor Fracture

Background Incarceration of the inferior oblique muscle (IO) branch of the oculomotor nerve may occur in cases of orbital floor trapdoor fracture.Cases Two orbital floor trapdoor fracture cases, with lesions located just outside of the inferior rectus muscle but without its incarceration, were examined pre- and postoperatively for visual acuity, intraocular details, the nine diagnostic ocular positions of gaze, binocular single vision field with the Hess chart, and by computed tomography (CT). One case was also examined by magnetic resonance imaging (MRI; T1-weighted images). A forced duction test was conducted intraoperatively.Observations Each case presented good visual acuity and neither globe showed any injury. Motility disturbance of the IO was shown in each case by binocular single vision field testing and the Hess chart. The possibility of the incarceration of the IO branch of the oculomotor nerve, which runs from the incarcerated lesion to the superior belly of the IO, in an orbital floor trapdoor fracture was shown on CT and MRI. Intraoperative forced duction testing revealed a restriction due to the incarceration of the connective tissue septa.Conclusions As inferred from the CT and MRI analyses conducted in this study, IO palsy may be one of the causes of ocular motility disturbance of the IO in an orbital floor trapdoor fracture, in addition to the ocular motility disturbance due to the connective tissue septa. Jpn J Ophthalmol 2005;49:246–252 © Japanese Ophthalmological Society 2005     

鼻内窥镜下经筛窦治疗爆裂性眶内壁骨折

目的探讨鼻内窥镜下经筛窦治疗爆裂性眶内壁骨折的临床疗效。方法25例爆裂性眶内壁骨折在鼻内窥镜下切除筛窦房隔及外伤损伤的眶纸板，将制备好的多孔硅胶片，凸面向外填塞进筛窦术腔，对眶纸板进行施压复位。结果随访3月-2年，治愈22例，占88．00％。2例术后残留周边复视，总有效率为96．00％。术后无眶内感染或其他并发症。结论鼻内窥镜下经筛窦治疗眶内壁骨折是有效的方法，疗效稳定，创伤小、手术时间短而且面部不留瘢痕，硅胶片可以长期存留。     

Optic Neuropathy with Delayed Onset After Trauma: Case Report and Review of the Literature

The authors report a case of a 16-year-old healthy male who experienced loss of vision in the right eye immediately after getting punched by a fist. His visual acuity improved to 20/20 within hours, and the optic nerve head appeared normal. Computed tomography (CT) scan of the orbits showed fractures of the right inferior orbital wall and lamina papyracea. The morning after the injury, he awoke with right eye vision decline to count fingers. There was pallid optic nerve swelling. Magnetic resonance imaging (MRI) scan of the orbits showed right medial rectus enlargement and no optic canal abnormalities. The patient was treated with intravenous (IV) methylprednisolone with improvement in visual acuity. Literature of delayed traumatic optic neuropathy (TON) and anterior TON is reviewed.     

A Population-based Study of Corneal Arcus and its Risk Factors in Iran

Purpose: To determine the prevalence of corneal arcus, its risk factors, and its relationship to ocular and visual indices.

Methods: In this cross-sectional study, 300 clusters were randomly selected from Shahroud in the north of Iran, using multistage sampling. A total of 20 people were invited to participate from each cluster. After enrollment, all optometric, biometric and ophthalmic exams were conducted on site.

Results: Of 6311 people invited, 5190 (82.2%) participated in the study. The prevalence of corneal arcus was 23.3% (95% confidence interval, CI, 22.1–24.6), and 98.4% were bilateral cases. The prevalence of corneal arcus was higher in men (odds ratio, OR, 2.02, 95% CI 1.8–2.3, p?p?p?=?0.006), male sex (OR 1.30, p?=?0.001), diabetes (OR 0.7, p?p?=?0.003), outdoor activity (OR 1.4, p?=?0.006), systolic blood pressure (OR 1.01, p?=?0.012), and diastolic blood pressure (OR 0.99, p?=?0.016) were significantly correlated with corneal arcus. Including biometric components in another model, corneal thickness (OR 0.99, p?p?p?Conclusion: This study adds valuable information to the epidemiology of corneal arcus in Iran and the Middle East. In people aged over 60 years, nearly 50% of the study population had corneal arcus. Older age, male sex, smoking, and systolic hypertension were risk factors for corneal arcus. Corneal arcus was also associated with thin and flat corneas and shallow anterior chamber depth.     

Visual Outcomes Following Orbital Biopsy

Abstract

Background: The risks of orbital biopsy depend on the lesion’s location and relationship with surrounding structures. Complications include reduced vision, although visual outcomes following orbital biopsy are not widely reported.

Aims: To determine visual outcomes following orbital biopsy in Gartnavel General Hospital’s Oculoplastic and Oncology Service.

Methods: Case note review of 50 consecutive patients undergoing orbital incision or excision biopsy between January 2006 and December 2010. Data collected included preoperative clinical examination, radiological and histological features, preoperative and postoperative corrected distance visual acuity (CDVA) and surgical complications. The main outcome measure was change in CDVA. Mean follow-up duration was 1.32 years.

Results: Histological diagnoses following biopsy included idiopathic orbital inflammation (n?=?13) and lymphoma (n?=?9). Of the radiologically defined lesions, 86.7% were extraconal (13.3% intraconal). Extraconal lesions were anterior in 59.0% (41.0% posterior). Mean preoperative LogMAR CDVA was 0.10 which was maintained at day one post-biopsy, indicating the absence of immediate sight-threatening complications such as retrobulbar haemorrhage or optic nerve compression, and there was no significant reduction at one-year follow-up (p?=?0.239). Further analysis of change in CDVA showed no difference between: anterior and posterior lesions; extraconal and intraconal lesions; incision and excision biopsies; anterior and lateral surgical approaches.

Conclusions: CDVA is retained for one year following orbital biopsy. Significant visual loss is a very rare complication of this procedure.     

A Combined Orbital and Antral Approach to Surgical Decompression of the Orbit

A combined orbital decompression procedure has been found effective in treating proptosis. The procedure includes a lower eyelid incision by an ophthalmologist to expose the floor of the orbit, while a Caldwell-Luc antrotomy is performed simultaneously by an otolaryngologist. The ophthalmologist has a better view of the contents of the orbit and the anterior orbital floor. The otolaryngologist has better access to the posterior orbital floor and ethmoid sinus. Together, isolation and preservation of the second division of the fifth cranial nerve are facilitated. The headlight worn by each surgeon helps illuminate the other's field of dissection. This combined approach offers advantages over separate operations.     

Effects of Valsalva Maneuver on Ocular Biometric Parameters: Optical Low-Coherence Reflectometry Biometer Study

Purpose: To evaluate the effects of the Valsalva Maneuver (VM) on ocular biometry and intraocular pressure (IOP). Methods: This prospective observational study included 55 eyes of 55 healthy volunteers. Axial length (AL), central corneal thickness (CCT), anterior chamber depth (ACD), lens thickness (LT), corneal curvature (K-steep, K-flat and K-mean), corneal diameter (WtW), and pupil diameter (PD) were measured with a LenStar LS 900® biometer at rest and during VM. The IOP was also measured at rest and during VM measurements were compared. Results: The VM did not have any significant influence on AL, WtW, K-flat, and K-mean (p?>?0.05), but it decreased K-steep significantly (p?p?p?p?=?0.002). Conclusions: The VM might reversibly change in IOP and ocular biometry, so it should be considered during anterior segment examinations.     

Diurnal Alterations of Refraction,Anterior Segment Biometrics,and Intraocular Pressure in Long-Time Dehydration due to Religious Fasting

Purpose: To investigate the effects of dehydration due to fasting on diurnal changes of intraocular pressure, anterior segment biometrics, and refraction. Subjects and methods: The intraocular pressures, anterior segment biometrics (axial length: AL; Central corneal thickness: CCT; Lens thickness: LT; Anterior chamber depth: ACD), and refractive measurements of 30 eyes of 15 fasting healthy male volunteers were recorded at 8:00 in the morning and 17:00 in the evening in the Ramadan of 2013 and two months later. The results were compared and the statistical analyses were performed using the Rstudio software version 0.98.501. The variables were investigated using visual (histograms, probability plots) and analytical methods (Kolmogorov-Smirnov/Shapiro-Wilk test) to determine whether or not they were normally distributed. Results: The refractive values remained stable in the fasting as well as in the control period (p?=?0.384). The axial length measured slightly shorter in the fasting period (p?=?0.001). The corneal thickness presented a diurnal variation, in which the cornea measured thinner in the evening. The difference between the fasting and control period was not statistically significant (p?=?0.359). The major differences were observed in the anterior chamber depth and IOP. The ACD was shallower in the evening during the fasting period, where it was deeper in the control period. The diurnal IOP difference was greater in the fasting period than the control period. Both were statistically significant (p?=?0.001). The LT remained unchanged in both periods. Conclusions: The major difference was shown in the anterior chamber shallowing in the evening hours and IOP. Our study contributes the hypothesis that the posterior segment of the eye is more responsible for the axial length alterations and normovolemia has a more dominant influence on diurnal IOP changes.     

Cerebrospinal fluid leakage after dacryocystorhinostomy

The authors have encountered two presumptive cases of cerebrospinal fluid leakage associated with dacryocystorhinostomy. To understand better the pathophysiology, bilateral dacryocystorhinostomies and anatomic dissections were performed on three fresh cadaver specimens. The average distance from the superior bony nasal window to the floor of the anterior cranial fossa was 5.0 mm. The frontal sinus floor overlies the anterior portion of the nasal window, while the thinnest portion of cribriform plate overlies the posterior portion of the nasal window. A bony fracture of the anterior cranial fossa floor and/or cribriform plate resulted from (1) applying a rotational force to the Kerrison ronguer while enlarging the posterior nasal window or (2) fracturing an attenuated superior wall of an ethmoid air cell which has eroded into the orbital roof.     

A Biomechanical Evaluation of Auricular Cartilage Autografts in Orbital Floor Defect Repair

Objective: Auricular cartilage is used as a surgical implant in the management of orbital floor fractures. However, no specific parameters exist regarding the use/limitations of this potential graft. In order to determine the mechanical efficacy of adult auricular cartilage grafts, a mechanical model was developed and studied for structural threshold size limits.

Methods: Thirty-seven cadaveric auricular cartilage specimens were tested in a laboratory. A plexiglass baseplate was created with four different sized holes, defined as 1.0×, 1.2×, 1.4×, and 1.6× the mean minor axis of the specimens. Each specimen was used to bridge one hole under increasing loads until mechanical failure. Structural stiffness at three different loading stages, structural failure strength, and percent failure of the entire system for each defect size was calculated.

Results: Specimens tested on 1.0×, 1.2×, 1.4× and 1.6× defects demonstrated 0%, 0%, 20%, and 60% system failure rates, respectively. Structural stiffness curves showed a similar trend, with ANOVA demonstrating a significant difference in mechanical properties between defect sizes (p?=?0.03). The curve representing 1.6?× defect size demonstrated significantly reduced structural stiffness relative to 1.0×, 1.2×, and 1.4× curves. There was no statistical difference between 1.2× and 1.4× testing sets (p?=?0.09).

Conclusion: A clinically significant biomechanical and functional threshold exists between 1.2×and 1.4× defect sizes. Given a mean minor axis of 2.06?cm, orbital blow-out defects <2.4?cm (1.2?×?2.06?cm) are suitable for auricular cartilage grafts; fractures >2.4?cm may require a more rigid material. Cartilage grafts that allow failure, however, may better protect the globe in subsequent injury.     

Clinico-Radiologic Findings of Entrapped Inferior Oblique Muscle in a Fracture of the Orbital Floor

A 51-year old man presented with vertical and torsional diplopia after reduction of a blowout fracture at another hospital one year ago. He had no anormalies of head position and 14 prism diopters (PD) right hypertropia (RHT) in the primary position. In upgaze no vertical deviation was found, and hyperdeviation on downgaze was 35PD. Bielschowsky head tilt test showed a negative response. Distinct superior oblique (SO) and inferior rectus (IR) underaction of the right eye was noted but IO overaction was mild on the ocular version test. Double Maddox rod test (DMRT) revealed 10-degree extorsion, but fundus extorsion was minimal in the right eye.Thin-section coronal CT scan showed that there was no fracture line on the anterior orbital floor, but a fracture remained on the posterior orbital floor. Also, the anterior part of the right inferior oblique muscle was vertically reoriented and the medial portion of the inferior oblique muscle was not traced on the coronal CT scan. The patient underwent 14 mm right IO recession and 3 mm right IR resection. One month after the surgery, his vertical and torsional diplopia were eliminated in the primary position.