Diplopia after Hyaluronic Acid Gel Injection for Correction of Facial Tear Trough Deformity

A 38 Year-old-female presented with diplopia and bilateral lower eyelid swelling 1.5 months after hyaluronic acid filler injection of tear trough deformity. Comprehensive eye examination showed an inferior oblique muscle restriction on the right eye. Diplopia and bilateral lower eyelid puffiness were treated by injection of hyaluronidase which resulted in disappearance of both diplopia and bilateral lower eyelid puffiness.     

Thyroid associated ophthalmopathy: botulinum toxin A in the treatment of upper eyelid retraction--a pilot study.

PURPOSE: Eyelid retraction in patients with thyroid associated ophthalmopathy is a common cause of eye discomfort and a disfigured facial appearance. The aim of this pilot study was to evaluate the effects and safety of inducing a temporary partial ptosis of the eyelid through injection of botulinum toxin A into the levator palpebrae superioris muscle. METHODS: Nine patients were treated. They were followed up with ophthalmologic examinations and self-assessment questionnaires until the point at which they either required renewed treatment or had no residual effect of the first injection. Maximum follow-up time was twenty weeks. RESULTS: In all eyes but one there was a lowering of the eyelid position one week after treatment and all these patients reported an improvement of eye appearance and symptoms. There was variability in the degree of lowering of the eyelid with the same dose of injected botulinum toxin A. It was also difficult to predict the time interval needed for re-treatment. Ptosis impairing visual acuity was not a consequence of the treatment in any of the patients. One week after treatment two patients experienced increased diplopia but only one showed transient change in Lees screen measurement of eye motility. CONCLUSION: Botulinum toxin A injection may be used to lower the upper eyelid position in patients awaiting eyelid surgery. The treatment safely relieved symptoms and improved eye appearance. However, treatment was short term and difficult to predict. There is also an inherent risk of transient diplopia.     

The effect of omitting botulinum toxin from the lower eyelid in blepharospasm treatment

We randomly selected 26 patients with essential blepharospasm to receive either botulinum toxin or saline injection in their lower eyelids to evaluate the necessity of lower eyelid injection to relieve blepharospasm. As diplopia may occur from botulinum toxin injections for blepharospasm, most commonly from injection of the lower eyelid, and surgical relief of blepharospasm is often achieved by excision of only the upper eyelid protractors, omission of toxin from the lower eyelid seemed both desirable and possible. All patients received botulinum toxin in the upper eyelids, above the eyebrows, across the glabella, and near the lateral canthus. Thirteen of 15 patients who received saline in their lower eyelids had relief of spasm, with the same spasm-free interval as those who received toxin. We recommend avoiding injection of toxin in the medial two thirds of the lower eyelid in order to diminish the likelihood of diplopia from inferior oblique muscle paresis.     

Acute periscleritis – a variant of idiopathic orbital inflammation

We examined seven patients who had eyelid swelling, proptosis, conjunctival injection, mild orbital pain and visual loss. Although several patients had mild limitation of eye movement, none experienced diplopia. Simultaneous bilateral involvement occurred in two patients. All patients were treated with oral corticosteroids and promptly improved, although recurrences in several required repeat courses of therapy. We identified inflammatory thickening of the posterior ocular wall and Tenon's capsule in some patients by means of B-scan ultrasonography and computerized tomography. We call this variety of anterior orbital inflammation without significant extraocular muscle involvement acute periscleritis, which is distinguished from other forms of idiopathic orbital inflammation and scleritis.     

The application of temperature measurement of the eyes by digital infrared thermal imaging as a prognostic factor of methylprednisolone pulse therapy for Graves’ ophthalmopathy

Purpose: Graves’ ophthalmopathy (GO) involves autoimmune process resulting in proptosis, congestion, oedema and diplopia. Werner’s NOSPECS classification and clinical activity score (CAS) of GO cannot objectively describe the inflammatory status. Digital infrared thermal imaging (DITI) detects local temperature and may reflect the degree of orbital inflammation. The aim of this study was to evaluate the clinical application of the eye temperature measured by DITI. Methods: Forty‐six patients with GO receiving intravenously methylprednisolone pulse therapy (MPT) were included in this study. Local temperatures of the lateral orbit, upper eyelid, inner caruncle, medial conjunctiva, lateral conjunctiva, lower eyelid and cornea were measured with DITI before and after MPT. CAS, proptosis, eye movement (EOM) and diplopia were also recorded. Improvement of CAS was defined as at least one point decrease at either side of the eye, which was 0.5 score decrease as to the average of bilateral CAS. Results: Local temperatures of the eyes decreased after MPT. The mean value of temperature (MT) of 12 points including the lateral orbit, upper eyelid, inner caruncle, medial conjunctiva, lateral conjunctiva and lower eyelid of both eyes before MPT was 32.65°. The mean change of MT after MPT (△T) was ?0.22°. △T significantly negative‐correlated with basal MT (correlation coefficient = ?0.54, p = 0.004). Higher baseline MT and CAS before MPT correlated with higher possibility of improvement of CAS after MPT (p = 0.013 and 0.012, respectively). Baseline MT and CAS together correlated with improvement of CAS after MPT better than baseline CAS alone could do (area under the receiver operating characteristic curve: 82.81% and 66.63%, respectively). Conclusions: Basal temperature of the eyes measured by DITI was an objective indicator of inflammation of GO. Combining CAS and MT could better predict the outcome of MPT than CAS alone.     

Botulinum toxin type a for dysthyroid upper eyelid retraction

PURPOSE: To evaluate the safety and efficacy of botulinum toxin type A for treatment of eyelid retraction resulting from thyroid eye disease (TED) during the inflammatory phase of the condition. METHODS: In this prospective, nonrandomized case series, 18 patients with inflammatory eyelid retraction caused by active TED received botulinum toxin type A injection (10, 5, or 2.5 U) for treatment of upper eyelid retraction. Botulinum toxin type A (Allergan, Irvine, CA, U.S.A.) was injected transconjunctivally just above the superior tarsal border in the elevator complex of the upper eyelid. RESULTS: Seventeen of 18 patients (94%) demonstrated a reduced marginal reflex distance (MRD1) after botulinum toxin injection. The average change in MRD1 of the treated eyelid after injection was -2.35 mm (range, 0 to -8.0 mm). Of the 27 eyelids injected, 33% had a 0- to 1-mm drop in eyelid height, 30% had a 1.5- to 2-mm decrease, 22% had a 2.5- to 3-mm decrease, and 15% had a greater than 3-mm decrease in eyelid height. None of the treated eyelids were noted to increase in height. One patient showed no alteration inafter treatment. One patient had clinically MRD1 significant ptosis and one patient reported worsening of preexisting diplopia after injection. Three patients undergoing unilateral injection had relative contralateral eyelid elevation. All untoward effects resolved spontaneously without sequelae. CONCLUSIONS:: Botulinum toxin type A may be used in the inflammatory stage of thyroid eye disease to improve upper eyelid retraction. Individual response to treatment is variable, but this modality should be considered as a temporizing measure until stability for surgery is reached.     

Isolated medial rectus muscle rupture after a traffic accident.

A 30-year-old male suffered an orbital trauma due to a traffic accident. At the Emergency Unit, the patient presented with avulsion of the upper left eyelid in the medial canthus, wounds in the lower eyelid and the inferior canaliculus, conjunctival laceration, proptosis and palpebral hematomas. The patient reported persistent diplopia. During the examination, exotropia and total absence of adduction were observed. Computerized tomography (CT) revealed a discontinuity at the left medial rectus. No orbital fractures were identifiable. The medial rectus was still attached to its anatomic insertion at the globe. The discontinuity was suggestive of laceration or rupture of this muscle at approximately 10-12 mm from its insertion. Surgical exploration revealed total rupture of the medial rectus at approximately 12 mm from its insertion. The posterior edge of the damaged muscle was found and sutured to its anterior edge with 6-0 polyglactin. The following day, the eyes were completely straight and the patient did not mention any signs of diplopia. Botulinum toxin injection into the ipsilateral lateral rectus was not necessary. After six months of follow-up, the patient still reported no diplopia. When muscular laceration is suspected after an orbital trauma, early CT is recommended. The only procedures that assure a significant recovery of the normal function of the eye are early muscle repair and avoidance, if possible, of transposition surgery.     

Effect of eyelid botulinum toxin injection on lacrimal drainage

PURPOSE: To determine the effect of eyelid botulinum toxin injection on the lacrimal drainage and to assess the use of botulinum toxin in dry eye conditions. METHODS: Prospectively, three test groups were examined and one lacrimal system investigated in each person in each group. Botulinum toxin A (3.75 IU) was injected into the medial part of 13 lower eyelids of 13 normal test subjects and the medial part of nine lower eyelids in nine patients with dry eyes. A dose of 2.5 IU was injected into the medial part of 10 lower eyelids and the medial part of 10 upper eyelids of 10 patients with dry eyes. The drop test was used to determine the lacrimal drainage capacity and the blink output, before and after the injection. The subjective effect of the botulinum toxin injection on eye comfort was investigated. RESULTS: Three weeks after lower eyelid botulinum toxin injection, the mean blink output was reduced to 64% (1.19 of 1.87; P <.001) and 70% (0.94 of 1.35; P <.001) of the baseline values in the groups of normal subjects and patients, respectively. After injection in both the upper and lower eyelid, the mean blink output was reduced to 38% (0.54 of 1.41; P <.001) of the baseline value. The patients with dry eyes reported an improved eye comfort in six of nine cases after injection in the lower eyelid and in seven of 10 cases after injection in both the upper and lower eyelid. Adverse effects included one case of increased discomfort for 3 weeks after injection. CONCLUSION: Injection of botulinum toxin into the medial part of the eyelids decreased the lacrimal drainage, suggesting a new way to treat dry eye conditions. Further studies are required to assess the clinical value of this treatment.     

Amaurosis after lower eyelid laser blepharoplasty

The transconjunctival CO(2) laser approach to lower eyelid blepharoplasty was used to treat a 66-year-old man presenting with bilateral lower eyelid herniated fat without excess skin. Early postoperative examination revealed left eye blindness. This report presents clinical circumstances of this rare complication and further discusses the most likely causative factors.     

Primary palpebral and orbital ossification in pseudo-pseudohypoparathyroidism

PURPOSE: To present a case of ossification of the eyelid, episclera and orbit in a patient with pseudo-pseudohypoparathyroidism (pPHP). METHODS: A 20-year-old woman diagnosed with pseudo-pseudohypoparathyroidism underwent clinical and histopathological examination of calcified plaques of the right eyelid and orbit. The patient presented with a round face, tousled short hair and retarded speech. She had been diagnosed with pPHP at 3 years of age. During her first decade, calcified plaques developed in the right eyelid and orbit. Gradually, she developed horizontal diplopia, pseudo-ptosis and periorbital pain. Vertical eye movements were reduced to 10 mm, although levator function remained intact. Computer tomography scans of the orbit showed three separate dense structures. Radiographic findings also showed bilateral shortening of the fourth metacarpus and a calcified subcutaneous plaque in the left thigh. The patient's blood status revealed an elevated level of thyroid stimulating hormone, but was otherwise normal. The patient was treated with eltroxin and shortly afterwards regained normal hair and normal speech function. RESULTS: The calcified structures were removed surgically and almost normal eye movements were re-established. Histological examination of the excised tissue demonstrated bone formation. CONCLUSION: This is the first reported case of ossification of the eyelid and orbit in a patient with pseudo-pseudohypoparathyroidism.     

A Rare Case of Penetrating Trauma Resulting in Isolated Third Nerve Palsy

A 23-year-old male presented to the emergency department with right eye pain, right upper eyelid ptosis, blurry vision, and binocular diplopia that developed immediately after he bent over in a parking lot and the antenna of a car penetrated his right upper eyelid. An extensive workup was performed, and he was found to have an isolated traumatic oculomotor nerve palsy with pupil involvement. No other ocular findings of a traumatic injury were present. The patient was observed for 14 months, during which he continually improved, with almost complete resolution of his diplopia, anisocoria, and ptosis.     

Treatment of upper eyelid retraction associated with thyroid eye disease with subconjunctival botulinum toxin injection

OBJECTIVE: To study the effectiveness of botulinum toxin injections, via a subconjunctival approach, in the management of upper eyelid retraction associated with thyroid eye disease. DESIGN: Prospective, non-comparative, interventional case series. PARTICIPANTS: Eleven patients with upper scleral exposure associated with thyroid eye disease who declined conservative or conventional surgical management. INTERVENTION: One or more treatments with injections of botulinum toxin into the subconjunctival space at the superior margin of the tarsal plate, via a conjunctival approach. MAIN OUTCOME MEASURES: Upper eyelid position in relation to the upper limbus, patient satisfaction, and complications. RESULTS: All patients experienced some improvement in the amount of lid retraction after injections. The amount of lid lowering varied between patients and lasted between 1 and 40 months. A lid position acceptable to the patient was obtained in 10 patients. Four patients had ptosis lasting from 1 to 3 weeks, and three patients had transient diplopia lasting 1 day to 3 weeks. CONCLUSIONS: This subconjunctival method of botulinum toxin injection provides an effective treatment for upper eyelid retraction associated with thyroid eye disease that is easy to administer and well tolerated by patients with few side effects.     

Inferior rectus pulley hindrance: a mechanism of restrictive hypertropia following lower lid surgery.

PURPOSE: This article describes a new mechanism of restrictive strabismus associated with inferior rectus (IR) pulley hindrance complicating lower eyelid surgery. METHODS: We studied five patients who developed hypertropia in infraduction after bilateral lower eyelid surgery. Complete ophthalmologic examination and multipositional, high-resolution orbital imaging by computed X-ray tomography (CT), or magnetic resonance imaging (MRI) was performed. Comparison was made with MRI in normal volunteers. RESULTS: There was restriction to passive infraduction of the involved eyes. Sagittal MRI images showed hindrance to normal posterior shift of the IR pulley from central to infraducted gaze. Intraoperative findings of contracture of the inferior fornix and dense fibrous scar tissue from the inferior orbital rim to the IR pulley complex correlated with restricted infraduction and imaging findings. Release of the scar tissues around the IR pulley improved infraduction, reducing or eliminating diplopia. CONCLUSION: Scar formation hindering anteroposterior travel of the IR pulley system is a novel mechanism of restrictive hypertropia in infraduction following lower eyelid surgery. This restrictive strabismus, the iatrogenic equivalent of retroequatorial myopexy, is distinct from paralytic strabismus and must be managed differently. Avoidance and treatment of this complication of lower eyelid surgery requires knowledge of anatomical relationship between the IR pulley and lower eyelid.     

Collagen shield contact lens use after eyelid surgery.

The use of collagen shields to enhance comfort and facilitate recovery after eyelid surgery was studied. Thirty-two patients undergoing various eyelid procedures were studied. In 10 patients, bilateral surgery was performed and the contralateral eye was used as a control. In patients with unilateral surgery, 20 of 22 patients exhibited comfortable postoperative courses, and in patients with bilateral surgery, eight of 10 patients had less conjunctival injection, chemosis, corneal staining, or lid edema on the side with the collagen shield. The only complications occurred with the 72-h lens, which tended to irritate the cornea and have a variable dissolution time.     

No Light Perception Vision From Compressive Thyroid Orbitopathy

Abstract

Thyroid eye disease (TED) is an autoimmune inflammatory disorder that affects the extraocular soft tissues and causes eyelid retraction, proptosis and restrictive extraocular myopathy. Compressive optic neuropathy from extraocular muscle enlargement occurs in less than 5% of patients, in the majority of whom it develops within 18 months of the diagnosis of hyperthyroidism. Vision loss from compressive optic neuropathy in patients with thyroid eye disease is usually bilateral and insidious in onset and progression and is associated with diplopia and elevated intraocular pressure. To our knowledge, there have been no reported cases of acute vision loss to the level of no light perception secondary to thyroid orbitopathy. The authors report a 66-year-old Caucasian male with history of long-standing thyroid eye disease and massive proptosis who progressed from mild compressive symptoms to no light perception within days, despite being clinically stable for over 10 years.     

Diplopia following porous polyethylene orbital rim onlay implant

An 81-year-old man with ocular irritation associated with lower eyelid retraction, horizontal laxity of the lower eyelids, and hypoplastic inferior orbital rims underwent bilateral placement of porous polyethylene orbital rim onlay implants. Two weeks after surgery, he developed vertical binocular diplopia on downgaze. Examination of extraocular motility demonstrated limited infraduction OD. Surgical exploration revealed scarring in the anterior orbit between the inferior rectus pulley and the orbital implant. The orbital implant was found to lie higher than the inferior orbital rim. After surgical lysis of the scar and reduction of the vertical height of the implant, the patient's diplopia resolved. Orbital connective tissues critical to ocular motility may be abnormally superficial in orbital rim hypoplasia. Onlay grafts must be carefully placed so that they do not interfere with these tissues.     

Epstein-Barr positive T-cell lymphoma in the ocular region

PURPOSE: To present two cases of rapidly growing tumors in the ocular adnexa. Both tumors were Epstein-Barr virus (EBV) positive peripheral T-cell lymphoma. METHODS: Case 1 was a 60-year-old man with a non-tender ulcerating tumor involving the lateral third of both upper and lower right eyelid. Case 2 was a 55-year-old man with a swelling of the left eyelid expanding cranially and dislocating the left eye, resulting in proptosis and diplopia. Both patients underwent incisional biopsy that did not disclose the malignant nature of the tumors. Clinical evaluation resulted in suspicion of malignancy and surgical excision was performed. RESULTS: The tumors were found to be consistent with EBV-positive peripheral T-cell lymphoma. CONCLUSIONS: Peripheral T-cell lymphoma is uncommon but a diagnosis to be considered in a patient with a tumorous lesion in the eye region. Furthermore, peripheral T-cell lymphoma may be EBV-positive.     

Bilateral upper and lower eyelid severe psoriasiform blepharitis: case report and review of literature

The purpose of the present study is to describe a case of severe, psoriasiform blepharitis by means of a case report and literature review. A 44-year-old man developed chronic blepharitis and tearing months after bilateral cataract surgery. Exam showed diffuse quad-eyelid erythema, discharge, edema, madarosis, and scale. He also had insufficient tear drainage due to bilateral upper eyelid cicatricial punctal atresia with bilateral lower eyelid punctal stenosis. Biopsy of the lower eyelids exhibited psoriasiform hyperplasia. Topical 0.1% tacrolimus achieved improvement but caused some subjective eye irritation. Psoriasiform dermatitis manifesting on the eyelids is rare, may be associated with insufficient tear drainage, and may respond favorably to 0.1% tacrolimus.     

Eyelid and orbital treatment following radical maxillectomy

Malignant lesions of the nasopharynx and paranasal sinuses often encroach upon the orbit. A series of nineteen patients who underwent partial or radical maxillectomy is presented to summarize the eyelid and orbital findings that required further treatment. Fifteen of these patients were left with an intact globe and a visually useful eye, but the defects of epiphora, eyelid malposition, dacryocystitis, and diplopia were visually threatening and required treatment. The cosmetic deformities and diplopia following maxillectomy and radiation are partially amenable to treatment with late bone grafting. Lacrimal outflow deficiencies were successfully treated with dacryocystorhinostomy. Only patients with ocular complications following maxillectomy are included in this series; therefore, the range of problems and their treatment confronting the ophthalmologist is summarized.     

Reverse ptosis-induced corneal steepening and decreased vision after LASIK surgery

PURPOSE: To report a patient with a past history of LASIK who had decreased vision and induced corneal steepening after lower eyelid ptosis. Surgical correction of lower eyelid ptosis decreased the corneal steepening and improved visual acuity. METHODS: Interventional case report. RESULTS: A 37-year-old woman had a history of bilateral LASIK, childhood strabismus surgery, and multiple surgeries to release scarring and improve motility in her left eye. Last surgery to release scar tissue resulted in reverse ptosis (lower eyelid ptosis) and decreased visual acuity from induced corneal steepening. Correction of lower eyelid ptosis by reinsertion of the retractor complex resulted in decreasing corneal steepening, improved visual acuity, and good anatomic position of the lower eyelid. CONCLUSION: Lower eyelid ptosis may induce corneal steepening and decreased vision after LASIK. Surgical correction of ptosis can decrease the extent of steepening and improve visual acuity.