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PubMed1996

Smoking and endocrine ophthalmopathy: impact of smoking severity and current vs lifetime cigarette consumption.

OBJECTIVE: Smoking has been associated with an increased incidence of endocrine ophthalmopathy (EO). In this study we examined the relation between smoking severity and the incidence of EO symptoms in patients with Graves' hyperthyroidism. DESIGN: Patients were prospectively followed for at least one year after the onset of hyperthyroidism. Smoking and EO status were evaluated at 3-6- months intervals. PATIENTS: Two hundred and fifty-three ambulatory patients with recent onset of Graves' hyperthyroidism were studied. MEASUREMENTS: The incidence of total EO symptoms, proptosis, and diplopia at any time point before and after the occurrence of Graves' hyperthyroidism was assessed by interview and physical examination. RESULTS: Smoking was associated with a 1.3-fold increase in the overall incidence of symptomatic EO, and a 2.6 and 3.1-fold increase in the incidence of proptosis and diplopia, respectively. The relative risk increased in parallel with the current number of cigarettes smoked per day. In contrast, lifetime tobacco use was not an independent risk factor for the development of EO symptoms. Former smokers had a significantly lower risk for the occurrence of proptosis and diplopia than active smokers with a comparable lifetime cigarette consumption. CONCLUSIONS: Our data suggest that current, but not lifetime, tobacco consumption constitutes a risk for the incidence of proptosis and diplopia in patients with Graves' hyperthyroidism, and that this risk increases with smoking severity.

Adult↗
PubMed2001

Minimization of zygomatic complex fracture treatment.

The aims of this non-randomized prospective study were to establish and justify minimized therapy for zygomatic complex fractures. Fifty-two consecutive patients were examined and classified with conventional routine radiographs. Preoperative symptoms were recorded. Treatment of zygomatic fractures was by percutaneous hook reduction and miniplate fixation along the frontozygomatic suture. Exploration of the orbital floor was carried out only in cases of primary diplopia or comminuted fractures. Postoperatively, patients were followed for 12 months. Clinical and radiologic assessment of reduction was symmetric and stable in all cases. Preoperative symptoms disappeared completely except for sensitivity disturbance in five patients. Patients with no post-trauma diplopia did not develop eye motility disturbances or enophthalmos. The treatment of a zygomatic fracture is possible by the described technique. Exploration of the orbital floor is indicated only in cases of preoperative diplopia. Therefore, a patient with a zygomatic fracture and diplopia should be classified as having a orbitozygomatic fracture. In cases of comminuted fractures, exploration of the orbital floor remains mandatory.

Adolescent↗
PubMed1998

[Skew deviation].

BACKGROUND: Skew deviation is a vertical ocular misalignment of prenuclear origin. Although well described in the literature, it is still probably underdiagnosed. Natural history of skew deviation is not well described in the literature. PURPOSE: To describe the clinical presentations, etiologies and follow-up of skew deviation. METHODS: Retrospective study of 29 patients diagnosed with skew deviation between 1993 and 1996. RESULTS: The commonest cause was cerebrovascular accident (12/29) and the commonest localisation was mesencephalic (9/29). Other causes included surgery (7/29), tumor (4/29), trauma (3/29), degeneration (3/29), inflammatory (2/29), increased intracranial pressure (1/29). Other localisations included cerebellum (5/29), ponto-mesencephalic (3/29), and medulla (2/29). Vertical diplopia was always accompanied by other neuro-ophthalmologic abnormalities. 69.2% (18/26) patients were totally asymptomatic after 7.5 months. 30.8% (8/26) were still symptomatic (diplopia). One patient required surgery, three patients were relieved with prisms, one patient needed monocular occlusion. One patient died during follow-up and precise data were lacking in two symptomatic patients. CONCLUSION: Skew deviation is not so rare, 10% of the cases referred to us for diplopia in 3 years. The diagnosis of skew deviation should be entertained when vertical diplopia cannot be explained by pathology of extraocular muscles, peripheral or central cranial nerve III or IV palsies, myasthenia, or orbital pathology. Prognosis for recovery in patients with skew deviation is good. 70% will recover, after a median time of 7.5 months. Surgery should be postponed at least for 12 months.

Adolescent↗
PubMed2003

Orbital floor reconstruction with flexible Ethisorb patches: a retrospective long-term follow-up study.

OBJECTIVE: The purpose of the study was to investigate whether a flexible, biodegradable material (Ethisorb) shows better long-term results with regard to diplopia, bulbus motility, and exophthalmos/enophthalmos compared to the use of lyophilized dura-patches and polydioxanone (PDS) foils. METHODS: During a period of 6 years 435 patients with an orbital fracture were investigated retrospectively. Inclusion criteria were patients with fractures of the orbital floor with a maximum size of 2 x 2 cm. Bulbus motility, exophthalmos, enophthalmos, and diplopia were investigated during a period of 2 years. RESULTS: One hundred twenty orbital floors were reconstructed by lyophilized dura-patches, 81 by PDS, and 136 by Ethisorb. An exploration without an implantation was performed in 91 patients. The long-term investigation 12 to 15 months after surgery showed an exophthalmos and enophthalmos incidence of 1%, whereas a reduced bulbus motility and diplopia were found in 5% and 4%, respectively. Fifteen to 24 months after surgery 2% of the patients had an exophthalmos and 1% had an enophthalmos. A reduction of bulbus motility was found in 4% of the patients, and diplopia was found in 3%. The use of Ethisorb resulted in a significantly lower incidence of exophthalmos 3 months after surgery compared to PDS. CONCLUSION: The low rate of acquired bulbus motility demonstrates acceptable results in using Ethisorb in the floor of the orbit.

Absorbable Implants↗
PubMed2003

Strabismus following endoscopic orbital decompression for thyroid eye disease.

Endoscopic orbital decompression may be used to treat disfiguring proptosis or sight threatening optic nerve compression in patients with thyroid eye disease. Strabismus is common in thyroid eye disease and frequently follows decompression surgery. We retrospectively reviewed patients undergoing endoscopic decompression for thyroid eye disease, by a single surgeon, from 1994 to 2000. Twenty-three patients (21 female, 2 male) were identified with a mean age of 47.5 years. At presentation, 21 patients had proptosis, 8 optic nerve compression (2 without proptosis) and 11 strabismus (9 complained of diplopia) with a mean BSV score of 24.5 before decompression. Forty orbits were decompressed with a mean decrease in proptosis of 3.3 mm. Following decompression, the mean BSV score was 25, and 17 patients had manifest strabismus in primary gaze (3 at near only) of whom 10 had pre-existing strabismus. Five patients had new diplopia (22%). Eleven patients ultimately required strabismus surgery of whom 8 had manifest strabismus before decompression. Following strabismus surgery, the mean BSV score was 37. The final BSV score for those not requiring strabismus surgery was 29. Mean follow-up was 28 months. Endoscopic orbital decompression can effectively treat disfiguring proptosis. Diplopia is a common complication, but pre-existing diplopia may improve.

Adult↗
PubMed2003

Endoscopic endonasal or transmaxillary repair of orbital floor fracture: a study of 88 patients treated in our department.

OBJECTIVES: Endoscopic repairs of orbital floor fractures performed in our department were reviewed and postoperative outcomes were assessed. MATERIAL AND METHODS: The subjects comprised 88 patients who underwent surgery between 1991 and 2001, 14 of whom had trapdoor fractures. Endoscopic repair was performed when diplopia did not improve after 1 week of conservative treatment. Fractures were repaired via endonasal or transmaxillary routes and fixed with a urinary bladder catheter. RESULTS: The postoperative course was evaluated on the basis of change in diplopia. After surgery, diplopia resolved in 79.5% of patients but remained, especially on upward gaze, in 20.5% of patients. Residual diplopia was more common in patients with trapdoor fracture. CONCLUSION: Endoscopic endonasal and transmaxillary repairs were effective and less invasive methods for freeing orbital tissues trapped by fragments of fractured bone and for restoring smooth ocular movements. However, suspected trapdoor fractures should be repaired within 1 week after injury in order to prevent fibrosis from developing in orbital tissues owing to entrapment by bone fragments.

Adolescent↗
PubMed1985

Effect of stimulus parameters on fusional and stereoscopic performance.

The effect of stimulus size and complexity on the horizontal divergent diplopia threshold, stereoscopic range, reappearance of stereopsis, and re-fusion point was examined. It was found that the addition of random-dot (RD) backgrounds significantly increased both the diplopia threshold and re-fusion point, whereas the further addition of multiple depth planes did not. Stereopsis and diplopia were found to coexist in RD stereograms both when the disparity increased past the diplopia threshold and when it was decreasing toward the re-fusion point. This suggests that monocularly distinguishable contours must be added to RD stereograms to render them suitable for the measurement of fusional amplitudes.

Adult↗
PubMed1997

Orbital decompression for thyroid orbitopathy.

BACKGROUND: Severe thyroid orbitopathy may result in optic neuropathy, corneal exposure and disfiguring proptosis. Orbital decompression has most commonly been performed for optic neuropathy, but with improved techniques, more patients are undergoing decompression for other indications. PURPOSE: This report evaluates the results and morbidity of orbital decompression for thyroid orbitopathy performed by one surgeon. METHODS: The records of 33 patients (53 orbits) undergoing orbital decompression for thyroid orbitopathy were analysed for changes in visual acuity and colour vision (where the indication was optic neuropathy) and reduction in proptosis. Complications were also analysed. RESULTS: Visual acuity and colour vision improved in all 33 eyes with optic neuropathy in the short term postoperative period (4 weeks), but later deteriorated in five eyes (6.6%) of 4 patients (19%). Proptosis decreased by a mean 5.3 mm (range, 1-10). Diplopia developed or worsened overall in 10 of 33 patients (30%), but only in one of 12 (8%) where the indication was cosmesis or corneal exposure. Diplopia improved in 2 of 33 (6%). All patients with symptomatic diplopia achieved binocular single vision in a useful range after one and sometimes two squint procedures. No patient lost vision as a result of surgery. CONCLUSIONS: Orbital decompression is effective in improving vision in most patients with thyroid optic neuropathy, but induces or worsens diplopia in a high proportion of these patients. Proptosis can be effectively and dramatically improved.

Adult↗
PubMed1996

Lamotrigine high-dose tolerability and safety in patients with epilepsy: a double-blind, placebo-controlled, eleven-week study.

PURPOSE: This study was undertaken to evaluate the dose tolerability and safety of a chronic ascending twice-daily (b.i.d.) dosage regimen of < or = 700 mg/day lamotrigine (LTG) and to include determination of the LTG pharmacokinetic profile at doses > or = 500 mg/day in patients receiving concomitant enzyme-inducing antiepileptic drugs (AEDs). METHODS: Twelve adult male epileptic patients treated with enzyme-inducing AEDs received < or = 700 mg/day (b.i.d.) oral LTG (n = 8) or placebo (controls, n = 4). For 3 weeks, as outpatients they had their LTG dosage increased from 100 to 400 mg/day. Then, in a clinical research study unit, patients received regimens of 500, 600, and 700 mg/day for 1 week each. Controls received matching placebo in the same sequence. At study end, dosages were tapered in 2 weeks. Follow-up evaluations were made 7 days later. RESULTS: Five LTG patients tolerated 700 mg/day for 1 week. LTG was reduced to 600 mg/day in a patient with mild diplopia and to 500 mg/day in a patient with mild oscillopsia and diplopia. One patient discontinued 300 mg/day therapy with a moderately intense diffuse papular skin rash, attributed to LTG. Headache, drowsiness, faintness, and diplopia, the common adverse events (AEs), were mild to moderate in intensity and occurred in 50-75% of patients in both groups (except for diplopia, occurring only with LTG). Concomitant AED plasma concentrations were not markedly changed by LTG. LTG pharmacokinetics were linear over the range of 500-700 mg/day. CONCLUSIONS: LTG doses < or = 700 mg/day can be tolerated in patients receiving concomitant enzyme-inducing AEDs.

Adolescent↗
PubMed1995

Sensory adaptations in Duane's retraction syndrome.

Knowledge of the sensory status of patients with Duane's retraction syndrome is limited. Fourteen patients with type A Duane's retraction syndrome, aged 6 to 22 years, were assessed prospectively and their sensory findings and the nature of their sensory symptoms detailed. All 14 patients had corrected monocular Snellen acuities of 6/9 or better. Six patients were asymptomatic and 5 of these had dense suppression on lateral versions, were free of diplopia and had variable stereopsis. The 5 bilateral cases were among the asymptomatic group. The remaining 8 patients had weak or absent suppression on lateral versions, variable horizontal diplopia and relatively normal stereopsis. Six were aware of diplopia but were never bothered by it and two spontaneously complained of symptoms related to abnormal binocularity (diplopia in one and asthenopia at near in both). It was not [corrected] possible to differentiate the 2 symptomatic cases from the former 6 on the basis of their sensory findings. Patients with type A Duane's retraction syndrome spontaneously complained of symptoms related to abnormal binocularity. The patients least likely to suffer sensory symptoms were bilateral cases or patients with dense suppression on lateral versions, irrespective of their stereoacuity levels.

Adaptation, Ocular↗
PubMed2004

Treatment of thyroid associated ophthalmopathy with periocular injections of triamcinolone.

AIM: To evaluate the efficacy of periocular triamcinolone acetonide for the treatment of thyroid associated ophthalmopathy (TAO), and the presence of ocular or systemic adverse effects. METHODS: A multicentre prospective pilot study was performed on patients diagnosed with Graves' ophthalmopathy less than 6 months before entry to the study. Patients were admitted to the study and were randomised into two groups: treatment and control. The treatment group received four doses of 20 mg of triamcinolone acetate 40 mg/ml in a peribulbar injection to the inferolateral orbital quadrant. Both groups were evaluated by measuring the area of binocular vision without diplopia on a Goldmann perimeter and the size of the extraocular muscles on computed tomography (CT) scans. Ophthalmological and systemic examinations were done to rule out ocular and systemic adverse effects. Follow up was 6 months for both groups. RESULTS: 50 patients were eligible for the study. 41 patients completed the study. There was an increase in the area of binocular vision without diplopia in the treatment group (Sigma initial: mean 231.1 (SD 99.9) and final absolute change, mean 107.1 (SD 129.0)) compared to the control group (Sigma initial: mean 350.7 (SD 86.5) and final absolute change, mean -4.5 (SD 67.6)). The sizes of the extraocular muscles were reduced in the treatment group (mean (inferior rectus initial values): 1.3 (0.7), final percentage change: -13.2 (25.7), medial rectus initial values: 1.2 (0.6), final percentage change: -8.2 (20.7), superior rectus-levator palpebrae initial values: 1.2 (0.6), final percentage change: -9.5 (29.1), lateral rectus initial values: 1.0 (0.4), final percentage change: -11.5 (20.6)) compared to the control group (inferior rectus initial values: 0.9 (0.3), final percentage change: -4.0 (21.5), medial rectus initial values: 0.9 (0.3), final percentage change: 0.6 (22.4), superior rectus-levator palpebrae initial values: 0.9 (0.3), final percentage change: 12.5 (37.5), lateral rectus initial values: 0.9 (0.4), final percentage change: -0.5 (31.6)). Both measurements (degree of diplopia and muscle thickness) were statistically significant between groups (initial - final). No systemic or ocular adverse effects were found. CONCLUSIONS: Triamcinolone administered as a periocular injection is effective in reducing diplopia and the sizes of extraocular muscles in TAO ophthalmopathy of recent onset. This form of treatment is not associated with systemic or ocular side effects.

Adult↗
PubMedDate not supplied

Orbital lipogranuloma after sinus surgery.

PURPOSE: To report the treatment and histopathological findings in two cases who developed eyelid swelling, proptosis and diplopia due to orbital and lid lipogranuloma after endoscopic surgery of the maxillary and ethmoidal sinuses. METHODS: To relieve the proptosis and diplopia, debulking surgery was done on the eyelids and orbit. The tissue removed was sent for histopathological examination. RESULTS: The two patients improved after surgery. The eyelid swelling, proptosis and diplopia subsided and ocular movements became normal. Histopathologic examination disclosed an extensive lipogranuloma. CONCLUSIONS: Extensive orbital and eyelid lipogranuloma causing proptosis and diplopia is a rare complication of endoscopic sinus surgery, and can be relieved by surgical debulking.

Adolescent↗
PubMed1998

Clinical evidence of extraocular muscle fiber-type specificity of botulinum toxin.

OBJECTIVE: To compare the effects of botulinum toxin on static and dynamic aspects of eye movements, and thereby elucidate the mechanisms of its action on eye muscles. BACKGROUND: Laboratory evidence indicates that static alignment and saccades are subserved by different extraocular muscle fiber types, and botulinum toxin may cause specific dysfunction of the fibers controlling static alignment. Diplopia is a well-known side effect of periorbital botulinum toxin injections in humans, and may be a clinical correlate of the laboratory findings. METHODS: Search coil recording of eye movements was performed in one patient with systemic botulism, and in three patients with diplopia following periorbital injection of botulinum toxin A. RESULTS: In the patient with acute botulism, eye movement alignment, range, and saccadic velocity profiles were abnormal. In three patients with iatrogenic diplopia, static alignment was abnormal but movement range and saccadic velocities were within normal limits. Edrophonium improved the range of movements and saccadic velocities in the patient with systemic botulism but was ineffective in reversing ocular misalignment in the one iatrogenic patient to whom it was administered. CONCLUSIONS: Precise alignment is subserved by orbital singly innervated muscle fibers, and the effects of botulinum toxin are greatest on these fibers. This predilection is apparent when the toxin dose is very small, as must have been the case in our patients with iatrogenic diplopia. The lack of a response to edrophonium probably reflects structural damage to muscle fibers. In contrast, larger doses of toxin produce an acute dysfunction of all extraocular muscle fiber types, which is responsive to edrophonium and consequently reflects partial blockade at the neuromuscular junction.

Adult↗
PubMed1977

Fractures of the orbital floor.

The charts of 324 patients treated for 363 orbital floor fractures between 1965 and 1973 were reviewed retrospectively. Of these, 38 (11 percent) were isolated floor fractures, 27 (8 percent) were rim and floor fractures, 168 (46 percent) were trimalar fractures and 130 (35 percent) were associated with complex facial fractures. On initial examination, 31 percent of the patients were found to have diplopia and 4 percent enophthalmos. Orbital prolapse was suspected in 31 percent of the patients. Thirty-seven percent of the patients had demonstrable ocular injury at the time of initial examination. Treatment was surgical in 336 of the fractures and non-surgical in 29. Of the surgical patients 140 had no support placed, 120 had antral support only, 51 had both antral support and orbital implant, and 20 had an orbital implant only. Postoperatively the incidence of diplopia was 8 percent in all patients, and 7 percent had enophthalmos. A smaller group followed for more than five months, were found to have diplopia in 17 percent and enophthalmos in 11 percent. Of the 29 patients treated non-surgically, none had persistent diplopia.

Diplopia↗
PubMed2005

Orbital decompression in Graves' orbitopathy: a combined endoscopic and external lateral approach.

AIMS: First, to assess the outcomes of endoscopic and external lateral orbital decompression in patients with dysthyroid orbitopathy. Second, to establish a correlation between the percentage of postoperative diplopia and the technique used. METHODS: A retrospective review of 40 patients (73 eyes) who underwent endoscopic medial orbital decompression and external lateral orbital decompression between 1997 and 2003 at the Hôpital Enfant-Jesus in Quebec City. Some of these patients also had an inferior endoscopic decompression. All patients had exophthalmos. The principal indications for surgery were 42 eyes with compressive optic neuropathy, 13 eyes with other ocular disorders, and 18 eyes with exophthalmos only. All patients with neuropathy underwent endoscopic decompression of the optic canal. RESULTS: All patients had satisfactory improvement of their ocular pathology. Optic neuropathy was completely resolved in 92.85% (39 of 42 eyes). In patients who did not have preoperative diplopia (26), diplopia developed in 70% (14 of 20) of those who underwent medial and inferior decompression compared with 16.6% (1 of 6) of patients who underwent medial decompression only. CONCLUSION: Endoscopic medial orbital decompression is very effective in resolving compressive optic neuropathy. Preservation of the orbital floor, when the degree of exophthalmos allows, reduces the incidence of postoperative diplopia.

Adult↗
PubMedDate not supplied

Thyroid eye disease presenting after cataract surgery.

Strabismus presenting after cataract surgery has been attributed to a variety of disorders, some of which are unrelated to the surgery. When thorough ophthalmologic and neurologic examinations fail to elucidate a definitive etiology, the motility disturbance is often ascribed to operative trauma to the orbital soft tissues. In a series of 58 patients with strabismus presenting after cataract surgery, eight (14%) were found to have previously unsuspected thyroid eye disease. Three of the eight patients had past histories of systemic dysthyroidism, but none reported diplopia prior to cataract extraction. Three of the remaining five patients showed normal thyroid function tests. Absence of diplopia prior to cataract extraction in these patients may be due to: 1) poor vision precluding diplopia until surgical restoration of sight; 2) intraoperative aggravation of the inflammatory process in otherwise subclinical thyroid eye disease; or 3) onset of clinical thyroid eye disease that was temporally associated with cataract surgery by chance. Thyroid eye disease should be included in the differential diagnosis of all patients presenting with binocular diplopia following cataract surgery. Suitable neuroimaging studies may be needed to confirm the diagnosis.

Aged↗
PubMedDate not supplied

Early surgery for dysthyroid orbitomyopathy based on magnetic resonance imaging findings.

PURPOSE: To investigate the value of magnetic resonance imaging (MRI) in the determination of the fibrotic phase in dysthyroid orbitopathy, which may be an indication for early surgery. PATIENTS AND METHODS: Thirteen patients with dysthyroid orbitopathy who had vertical deviation in excess of 20 PD and associated diplopia in the primary position that did not respond to medical treatment were included in the study. On MRI, the absence of high-intensity foci in the T2 sequence, especially in the coronal planes, indicated that the extraocular muscles were not edematous. These muscles were evaluated as being in the fibrotic phase, and surgery was performed without waiting the recommended 6 months for the stabilization of the angle of deviation. RESULTS: The complaint of diplopia disappeared after a single operation in 8 patients, and after a second operation in 4. Thus, success was obtained in 12 of the 13 patients. One patient with persistent vertical diplopia refused a second operation. CONCLUSION: Our results indicate that MRI is an effective and reliable method for the determination of the fibrotic phase in patients with dysthyroid orbitopathy who have diplopia in the primary position, and that MRI results have an important role in determining whether early surgery is appropriate.

Adult↗
PubMedDate not supplied

Endoscopic orbital decompression for Graves' ophthalmopathy.

BACKGROUND: Graves' ophthalmopathy generates a volume excess for the orbital cavity, which may produce proptosis, pain, exposure keratitis, diplopia, and optic neuropathy. Endoscopic orbital decompression expands the orbital cavity into the ethmoid cavity and medial maxillary sinus. This retrospective study documents the outcomes after endoscopic orbital decompression for patients with Graves' ophthalmopathy. METHODS: Data collected included demographic information, symptom resolution, complications related to the surgery, reduction in proptosis, subsequent need for eye muscle surgery, and hospital length of stay. Between July 1989 and April 2003, 62 patients were referred for endoscopic orbital decompression (often unilateral). RESULTS: Three patients refused use of their medical records for research purposes. Seventy percent were women; the average age of the study group was 49 years. Preoperatively, 63% of the patients had diplopia and optic neuropathy was noted in 27%. Two patients had a cerebrospinal fluid leak identified and managed during the decompression. No postoperative leaks occurred. Twenty-five percent of patients did not require eye muscle surgery. Forty-eight percent of the patients underwent one procedure to manage diplopia. The average reduction in proptosis was 2.5 mm. Fifty-four percent were managed as an outpatient and 27% underwent a 23-hour observation period. CONCLUSION: This data supports the safety, efficiency, and efficacy of endoscopic orbital decompression for unilateral and bilateral Graves' ophthalmopathy. Eye muscle surgery frequently will be required to manage diplopia after decompression.

Adult↗