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PubMed2004

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.

Adult↗
PubMed2004

Fourth and sixth cranial nerve injury after halo traction in children: a report of two cases.

BACKGROUND: Spinal traction is the application of a longitudinal force to the spinal column as a means of stabilizing a damaged or abnormal spine. Although not well documented in the ophthalmic literature, complications include cranial nerve palsies, with the sixth nerve being most commonly affected. Fourth nerve palsies have not previously been reported to our knowledge. We present 2 cases of combined fourth and sixth palsies after cervical traction. METHODS: Retrospectively, we reviewed the ophthalmic findings in 2 children with diplopia after spinal traction. RESULTS: Case 1 suffered a traumatic rotatory atlantoaxial subluxation and underwent halo traction. Case 2 required traction to correct a scoliosis secondary to osteogenesis imperfecta. In both cases, sixth nerve palsies were apparent soon after traction. Careful orthoptic examination revealed additional fourth nerve involvement. After 3 months, both cases showed partial resolution of the cranial nerve injuries. CONCLUSIONS: Cranial nerve injury may occur with spinal traction. Fourth nerve palsy may be underreported because of masking by a coinciding sixth nerve palsy.

Abducens Nerve Injury↗
PubMed2005

Combined adjustable rectus muscle resection--recession for incomitant strabismus.

INTRODUCTION: We sought to report the results of combined adjustable suture resection and recession of a rectus extraocular muscle in a subset of patients who are asymptomatic in the primary position but diplopic in secondary functional gaze positions. METHODS: We undertook a retrospective chart review of 12 patients who underwent a surgical procedure consisting of combined resection and recession of the same rectus extraocular muscle on adjustable suture, the amount of recession being double the amount of resection. RESULTS: The amount of incomitance reduced from a preoperative mean of 11.6 prism diopters (PD) to a postoperative mean of 2.9 PD. All 4 rectus muscles underwent operation No significant change in the primary position alignment occurred. Diplopia was eliminated in 11 of the 12 patients postoperatively. CONCLUSION: The combined adjustable suture resection and recession operation is an effective and easy procedure for treatment of this subset of patients with incomitant strabismus.

Adolescent↗
PubMed2006

Temporary incyclotorsion following surgical correction of bilateral superior oblique palsy.

We report three patients with acquired bilateral superior oblique paresis who had bilateral modified Harada-Ito procedures, which resulted in significant incyclotorsion (ranging from 6 degrees to 19 degrees ) on the first day postoperatively. For Case 1 this was the only procedure, while Cases 2 and 3 also underwent simultaneous bilateral inferior oblique weakening. This overcorrection decreased spontaneously over the following 8 months to leave all patients asymptomatic. One patient returned 8 years following the initial surgery with symptoms of diplopia and recurrence of excyclotorsion.

Adolescent↗
PubMed2006

Artemis very high-frequency digital ultrasound-guided repositioning of a free cap after laser in situ keratomileusis.

We present a patient in whom a symmetrically round free cap occurred during laser in situ keratomileusis (LASIK), and flap repositioning was performed without laser ablation. A loss of 3 lines of best spectacle-corrected visual acuity (BSCVA), monocular diplopia, and topographic irregular astigmatism confirmed that the free cap orientation was incorrect. Two subsequent free cap rotations based on refraction failed to realign the free cap into its original position. Artemis 3-dimensional very high-frequency digital ultrasound analysis found the thickness profiles of the free cap and bed to be irregular and mismatched. The rotation required for anatomic realignment was determined by digitally generating a "lock and key" superimposition of the free cap and stromal bed thickness profiles. After Artemis-guided free cap rotation, the eye regained preoperative BSCVA and symmetrical corneal topography with a +0.50 diopter change in spherical equivalent.

Adult↗
PubMed2006

Traumatic oculomotor nerve palsy.

Traumatic isolated oculomotor nerve palsy is not common. Oculomotor nerve palsy without internal ophthalmoplegia (pupil sparing) is extremely rare. We report a case of this condition in a child. An 11-year-old boy was transferred to our hospital after a head injury in a traffic accident. Neuro-ophthalmic examination showed that the left eye had limited adduction, supraduction, and infraduction, incomplete convergence and left ptosis, but no internal ophthalmoplegia. Magnetic resonance imaging indicated mild bending of the ipsilateral oculomotor nerve at the posterior petroclinoid ligament. One month after injury, movement of the patient's eyes was normal on examination, but there was mild diplopia. The suggested mechanism of the oculomotor nerve palsy with pupil sparing in this case is stretching of the oculomotor nerve at the posterior petroclinoid ligament, maintaining an intact pupillomotor nerve.

Brain Injuries↗
PubMed2005

Reconstruction of orbital floor fracture with polyglactin 910/polydioxanon patch (ethisorb): a retrospective study.

PURPOSE: We sought to evaluate the effectiveness and the complications related to the use of Ethisorb (resorbable alloplastic material) in the reconstruction of orbital floor fractures. PATIENTS AND METHODS: We retrospectively reviewed the charts of all patients who underwent orbital floor fracture reconstruction with Ethisorb since 2001. We only included patients with a minimum follow-up of 3 months. The following data were recorded for every patient: age, gender, cause of trauma, time from trauma to surgery, signs and symptoms, concomitant ocular injuries, radiographic analysis, pertinent intraoperative findings (including the type of approach), follow-up time, and postoperative complications. RESULTS: Eighty-seven patients were included in the study. Twenty-one patients (24.1%) experienced postoperative complications. Of these, only 3 patients (3.4%) had permanent complications directly related to the Ethisorb membrane (diplopia, enophthalmos). Two of these patients required revision surgery and are discussed in the article. CONCLUSIONS: The results of our study demonstrate the effectiveness of Ethisorb in the repair of small-to-moderate orbital floor fracture defects (up to a maximum size of 2 x 2 cm).

Absorbable Implants↗
PubMed2004

Orbital myositis associated with Borrelia burgdorferi (Lyme disease) infection.

OBJECTIVE: To report on the clinical findings in a patient with isolated left inferior rectus myositis associated with serologically confirmed Borrelia burgdorferi infection. DESIGN: Interventional case report. TESTING: Comprehensive clinical, laboratory, and imaging evaluation. RESULTS: Contrast-enhanced computed tomography showed a swollen inferior rectus muscle with infraorbital soft tissue swelling in a patient with diplopia and prior symptoms consistent with manifestations of Lyme disease. Positive serum and cerebrospinal fluid antibodies to B. burgdorferi by enzyme-linked immunoassay were confirmed by Western blot, and the cerebrospinal fluid/serum antibody ratio was elevated. No alternative cause for orbital myositis was found, and treatment with antibiotics resulted in a complete recovery. CONCLUSIONS: Orbital myositis should be added to the expanding list of ophthalmic manifestations of Lyme disease. Correct diagnosis and appropriate antibiotic therapy may reduce the likelihood of further neurologic or ophthalmologic sequelae.

Adult↗
PubMed2005

Idiopathic repetitive oculomotor nerve palsies in otherwise normal patients.

OBJECTIVE: To describe a unique idiopathic disorder characterized by transient repetitive unilateral oculomotor pareses. DESIGN: Retrospective observational case series. PARTICIPANTS: Three women presenting for tertiary neuro-ophthalmologic evaluation. METHODS: Review of patient records. MAIN OUTCOME MEASURES: Historical information, clinical examination, neuroimaging, and laboratory evaluation for myasthenia gravis. RESULTS: Three 44- to 69-year-old women had recurrent unilateral ptosis over the course of 2 to 4 years. Two had concurrent diplopia with ipsilateral limitation of adduction, and 2 also had a large poorly reactive pupil in the involved eye during the episodes. The attacks lasted between 30 seconds and 4 hours and occurred up to 6 times daily. None of the patients were migraineurs, nor had they received radiation therapy. Neuro-ophthalmologically normal between episodes, all patients had normal magnetic resonance imaging/angiography and testing for myasthenia gravis. CONCLUSION: Transient, recurrent, unilateral oculomotor nerve palsies may occur spontaneously in healthy individuals. The pathogenesis remains obscure, but the multiple recurrences without evident sequelae and the failure to develop any systemic or neurological disorder suggest that this phenomenon is not indicative of a serious underlying disorder.

Adult↗
PubMed2006

Periocular and orbital amyloidosis: clinical characteristics, management, and outcome.

OBJECTIVE: To present the clinical features and management outcome in a large series of patients with periocular and orbital amyloidosis. DESIGN: Retrospective, noncomparative, interventional case series. PATIENTS: All patients diagnosed with periocular and orbital amyloidosis in 6 oculoplastic and orbital units. METHODS: Clinical records of all patients were reviewed. MAIN OUTCOME MEASURES: Clinical presentation, radiological and histological findings, treatment modalities, and outcome. RESULTS: The study included 24 patients (15 female, 9 male) with a mean age of 57+/-17 years. Nineteen cases were unilateral, and 5 were bilateral. Clinical signs and symptoms included a visible or palpable periocular mass or tissue infiltration (95.8%), ptosis (54.2%), periocular discomfort or pain (25%), proptosis or globe displacement (21%), limitations in ocular motility (16.7%), recurrent periocular subcutaneous hemorrhages (12.5%), and diplopia (8.3%). Seven cases had orbital involvement, and 17 were periocular. Immunohistochemistry in 7 patients showed B cells or plasma cells producing monoclonal immunoglobulin chains that were deposited as amyloid light chains. Only 1 patient was diagnosed with systemic amyloid light chain amyloidosis. Treatment modalities were mainly observation and surgical debulking. During a mean follow-up period of 39 months, 21% showed significant progression after treatment, whereas 79% were stable or showed no recurrence after treatment. CONCLUSION: Periocular and orbital amyloidosis may present with a wide spectrum of clinical findings and result in significant ocular morbidity. Complete surgical excision is not feasible in many cases, and the goal of treatment is to preserve function and to prevent sight-threatening complications.

Adult↗
PubMed2006

Fronto-ethmoid sinus mucocele: a case report.

BACKGROUND: Mucoceles are epithelium-lined cavities in the paranasal sinuses filled with mucus. They develop because of scarring and obstruction of the sinus ostium, whether from chronic sinusitis, trauma, or surgery. They commonly erode the bony sinus wall and can have serious complications of brain and orbital invasion, with potential for abscess and rupture. CASE REPORT: A 39-year-old woman had diplopia in left gaze and a hard nodule above the right eye for 1 year. She recently noted a bulging right eye, nasal congestion, and occasional headaches. She was 9 years post-sinus surgery. All aspects of the afferent optic nerve function were intact. Right-sided proptosis was evident as was a right adduction and supraduction deficit, prompting immediate imaging, both with a computed tomography scan and magnetic resonance imaging of the orbits. These results showed a large right ethmoid sinus mucocele, with bony erosion and orbital invasion, prompting an immediate surgical referral. CONCLUSION: Mucoceles may arise from any of the paranasal sinuses and, because of the close proximity of these spaces to the orbit, may initially manifest with visual and ocular signs and symptoms. Therefore, eye care providers need to be aware of this entity and the need for immediate referral or workup if a mucocele is suspected.

Adult↗
PubMed2006

Differential diagnosis and management of acquired sixth cranial nerve palsy.

BACKGROUND: Cranial nerve VI innervates the lateral rectus muscle. A lesion will result in esotropia greater at distance and an ipsilateral abduction deficiency. After the age of 50 years, vascular diseases are the most commonly known causes. CASE REPORT: A 55-year-old white man reporting a 2-week history of horizontal diplopia that was worse at distance was found to have a left sixth cranial nerve paresis. The patient was diagnosed with hypertension and placed on medications. At the 4-week follow-up visit, the abduction deficiency had resolved. DISCUSSION: The incidence of sixth nerve palsy is 11.3 in 100,000. A lesion anywhere along the course of the nerve, from the pons to the orbit, can cause a paresis or palsy. After ruling out trauma and non-neurological problems, cases should be classified into neurologically isolated or non-neurologically isolated cases. Neurologically isolated sixth nerve palsies are associated most commonly with vascular disease. Non-neurologically isolated sixth nerve palsies typically are associated with more grave conditions. CONCLUSION: A sixth nerve palsy of vascular or undetermined causes typically resolves within 6 to 8 weeks. If resolution does not occur within 2 to 3 months, the condition progresses, or if additional neurologic signs or symptoms develop, imaging studies are indicated.

Abducens Nerve Diseases↗
PubMed2007

Endoscopic versus external repair of orbital blowout fractures.

OBJECTIVES: This study evaluates the usefulness of endoscopic repair compared to external repair in the treatment of blowout fracture (BOF) of the orbit. STUDY DESIGN AND SETTING: This retrospective study comprised 100 patients who had had surgical repair of orbital BOF since 1992. Forty-eight of the 100 had undergone endoscopic repair, 48 patients had had external repair, and four patients underwent surgery that combined the two approaches. The two basic approaches were evaluated and compared with respect to technique, results and complications. RESULTS: Endoscopically, transnasal and transantral approaches had been used for reduction and support of fractured medial and inferior walls, respectively. In the external approach, various transorbital incisions were made and the fractured wall was repaired with alloplastic or autologous materials. Complete or partial resolution of preoperative diplopia was achieved in 94% of the endoscopic group and 83% of the external group (NS). Enophthalmos was improved in 89% of the endoscopic group and 76% of the external group (NS). Though the endoscopic group had no significant complications, the external group had ectropions, significant facial scars, extrusion of inserted Medpor, and intra-orbital hematoma. CONCLUSIONS: Endoscopic repair appears to be a safe and effective technique for the treatment of BOF of the orbit.

Adult↗
PubMed2005

Epidermoid cyst of the sphenoid sinus with extension into the sella turcica presenting as pituitary apoplexy: case report.

BACKGROUND: Epidermoids of the central nervous system are rare tumors. They are usually found in the fourth decade of life and most commonly off midline in the cerebellopontine angle. We report here a rare case of an epidermoid arising from the sphenoid sinus with extension into the sella and adjacent structures with acute onset of neurological deficit. The significance of the clinical presentation resembling pituitary apoplexy and magnetic resonance imaging (MRI) findings is noted. CASE DESCRIPTION: A 25-year-old man presented with acute severe headache, diplopia, and decreased visual acuity. Examination revealed right-sided ptosis and paresis of the third cranial nerve on the right side. Computed tomography and MRI were suggestive of a slow-growing sphenoid sinus mass with extension into the sella. The sublabial transsphenoidal approach was used to remove the mass under direct visualization. The patient's neurological status improved to baseline both subjectively and objectively after the operation. CONCLUSION: Epidermoids, although rare, should be considered as part of the differential diagnosis when evaluating lesions of sphenoid sinus or sellar origin.

Acute Disease↗
PubMed2006

Delayed traumatic ocular emphysema: a case report.

A 47-year-old man sustained fractures of the left orbita and zygomatic bone after a fall. He was advised to visit an oral and maxillofacial department for more detailed evaluation and treatment, but ignored the advice. Four days later, after sneezing and blowing his nose, he presented severe exophthalmos, diplopia, and reduction of vision. Two days after the symptoms presented he asked for oral and maxillofacial surgery consultation. He refused any surgical intervention and was treated conservatively. The recovery was slow and 1 week later he was discharged with slight esthetic problems.

Diplopia↗
PubMed2006

Blow-out fractures in children: six years' experience.

OBJECTIVES: To present and analyze our experience in treating blow-out fractures in children, over a 6-year period. STUDY DESIGN: The study was retrospective with 16 consecutive cases of blow-out fractures in children aged 5 to 15 years. All patients presented with impairment of eye motility and diplopia together with radiological findings. Treatment included fracture reduction, release of entrapped periorbital soft tissues, and placement of an alloplastic membrane on the orbital floor. Fractures were linear in 11 cases (trapdoor) and severe or comminuted in 5 cases. RESULTS: Clinical symptoms subsided in all cases. Complete recovery of eye motility was achieved after surgical procedure in 13 cases; 2 patients presented late but had full recovery, and 1 patient, 4 years postoperatively, still had slight motility impairment. CONCLUSIONS: Surgical treatment of blow-out fractures, including periorbital tissue release and placement of a membrane lining on the orbital floor, presented satisfactory results in our cases.

Adolescent↗
PubMed2006

The sub-clinical see-saw nystagmus embedded in infantile nystagmus.

A transient, decompensated vertical phoria in an individual with infantile nystagmus syndrome (INS) resulted in two images that oscillated vertically-a diplopic oscillopsia. Ocular motor studies during the vertical oscillopsia recreated by vertical prisms, led to the identification of a sub-clinical see-saw nystagmus (SSN), present under the prism-induced diplopic condition. Retrospective analysis of ocular motor recordings made prior to the above episode of vertical diplopia revealed the presence of that same sub-clinical SSN. The SSN had not been detected previously despite extensive observations and recordings of this subject's pendular IN over a period of forty years. Three- dimensional search-coil data from fourteen additional INS subjects (with pendular and jerk waveforms) confirmed the existence of sub-clinical SSN embedded within the clinically detectable horizontal-torsional IN in seven of the fifteen and a sub-clinical, conjugate, vertical component in the remaining eight. Unlike the clinically visible SSN found in achiasma, the cause of this sub-clinical SSN is hypothesized to be due to a failure of the forces of the oblique muscles (responsible for the torsional component of the IN) to balance out the associated forces of the vertical recti; the net result is a small, sub-clinical SSN. Thus, so-called "horizontal" IN is actually a horizontal-torsional oscillation with a secondary, sub-clinical SSN or conjugate vertical component. The suppression of oscillopsia by efference copy in INS appears to be accomplished for each eye individually, even in a binocular individual. However, failure to fuse the two images results in oscillopsia of one of them.

Diplopia↗
PubMed1989

Treatment of Graves' disease and the course of ophthalmopathy.

PURPOSE: Contradictory results have been obtained with regards to the effect of various treatment modes on the exacerbation of Graves' ophthalmopathy, probably because the number of patients in each study was small and some studies were analyzed only in relation to one type of treatment. To circument these problems, we studied the course of Graves' ophthalmopathy after various modes of therapy for thyrotoxicosis among 537 patients with Graves' disease. PATIENTS AND METHODS: A total of 537 patients with Graves' disease were prospectively studied over an 11-year period. Thirty-one patients were lost to follow-up during the first six months after treatment and were excluded from the study. Of those remaining, 426 received one form of treatment, 79 received two kinds of therapy, and one received three kinds of therapy. Thus, surgical treatments numbered 164, radioactive iodine-131 (131I) treatments numbered 241, and medical treatments numbered 182. Ocular signs were considered improved or exacerbated by the following criteria: decrement or increment of the exophthalmos of 2 mm or more, improvement or deterioration of visual acuity, and regression or progression of extraocular muscle involvement causing diplopia. RESULTS: Among patients who did not have infiltrative ophthalmopathy before treatment, there was no difference in the occurrence of posttreatment exophthalmos in the surgically, medically, and 131I-treated patients (7.1%, 6.7%, and 4.9%, respectively). The incidence and the degree of progression of ophthalmopathy in patients who already had exophthalmos before treatment were similar in the medically, surgically, and 131I-treated groups (19.2%, 19.8%, and 22.7%, respectively). Most of the progression occurred in the posttreatment euthyroid stage. The incidence of improvement of ophthalmopathy was also similar (14.1%, 12.6%, and 12.3% in the medically, surgically, and 131I-treated patients). CONCLUSION: In conclusion, we found no influence of type of therapy for thyrotoxicosis on the clinical course of Graves' ophthalmopathy in this retrospective study of 537 patients.

Adult↗