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PubMed1997

Detached superior rectus following scleral buckling: anatomy and surgical management.

We describe two patients who developed vertical diplopia following circumferential scleral buckling for retinal detachments. Both were found to have hypodeviation and impaired elevation of the operated eye. In each case this was initially ascribed to the presence of the buckle itself, but there was no clinical improvement when this was subsequently removed, and the insertion of the superior rectus was therefore explored. In both patients this muscle was found to be detached from its normal insertion, and was identified in a retracted position overlying the insertion of the superior oblique. Following surgical re-attachment of the superior rectus, ocular elevation was restored, with resolution of symptoms.

Aged↗
PubMed2000

Erdheim-Chester disease: two cases of orbital involvement.

Erdheim-Chester disease (ECD) is an increasingly recognised form of fibro-inflammatory process characterised by xanthomatous histiocytes containing large amounts of ingested lipid, plasma cells, macrophages and Touton-type giant cells. Ophthalmic involvement in ECD has been reported in only 22 cases. We describe two patients, one presenting with diabetes insipidus and subsequently developing orbital pseudotumours and retroperitoneal fibrosis, the other presenting with exophthalmos and diplopia. The first patient was treated with cladribine and subsequently developed sudden onset of bilateral blindness while the second required radiation therapy for the retro-orbital process and developed radiation retinopathy. These cases typify the variable presentation and course in patients with ECD.

Diplopia↗
PubMed2001

Combined strabismus and phacoemulsification cataract surgery: a useful option in selected patients.

PURPOSE: To evaluate the role of combined strabismus and phacoemulsification cataract extraction in patients with symptomatic cataract and strabismus. METHODS: Four procedures of combined strabismus and cataract surgery are described in 3 elderly patients with strabismus of differing aetiologies. Two patients underwent one procedure; the other patient underwent two combined procedures, one to each eye. RESULTS: The visual acuity improved in all 3 patients. Post-operative alignment of the visual axis was achieved which allowed resolution of symptomatic diplopia in patient 1, functional binocular single vision in patient 2 and a noticeably reduced compensatory head posture in patient 3. CONCLUSIONS: Combined strabismus and cataract surgery is a safe procedure that can optimise visual alignment and improve visual acuity with a minimum number of operations.

Aged↗
PubMed2002

A child with Miller Fisher syndrome.

We describe the case of a six-year-old girl who presented with a 3-day history of diplopia and gait disturbance following a febrile flu-like illness. On examination she was found to have ataxia, areflexia and ophthalmoplegia, and a diagnosis of Miller Fisher syndrome was made after the exclusion of other conditions. This report outlines the frequency of Miller Fisher syndrome and lists the differential diagnoses that should be considered in Australia. In addition, the occurrence of pupillary dysfunction is discussed.

Child↗
PubMed2000

Sino-orbital fistula: two case reports.

A fistula between the paranasal sinuses and the orbit as a late complication of orbital fractures is rare and may present with intermittent symptoms due to air passing into the orbit. A case note review of two patients with sino-orbital fistula is presented. Two patients, 23- and 30-year-old males, presented with intermittent symptoms of globe displacement, diplopia or discomfort months after repair of an orbital floor fracture with a synthetic orbital floor implant. The symptoms occurred after nose blowing. They were both cured by removal of the implant and partial removal of the tissue surrounding the implant. A sino-orbital fistula may complicate the otherwise routine repair of an orbital floor fracture, but may be cured by removal of the implant and part of the surrounding pseudocapsule.

Adult↗
PubMed2002

Orbital foreign body misdiagnosed as superior orbital rim fracture.

Orbital foreign bodies may be difficult to diagnose clinically and radiologically. In cases where a foreign body is suspected, both the mechanism of injury and the composition of the offending material need to be taken into account. A case is described of an orbital foreign body misdiagnosed as a superior orbital rim fracture, resulting in persistent ptosis and diplopia, and leading to delayed recovery for the patient, a commercial airline pilot.

Adult↗
PubMed2004

Late reactivation of thyroid orbitopathy.

BACKGROUND: Thyroid orbitopathy is characterized by spontaneous remissions and exacerbations. Although data on the natural history are scarce, the active phase is usually self-limited, encompassing an average period of 18-36 months. Late reactivation, defined as active orbitopathy occurring after more than 5 years of quiescent disease, appears to be an uncommon and poorly documented event. The aim of the present study was to assess the incidence and characteristics of late reactivation of thyroid orbitopathy within a tertiary referral orbital clinic. METHODS: A retrospective case review was conducted of patients with thyroid orbitopathy seen at the Royal Adelaide Hospital Orbital Clinic between 1996 and 2001. RESULTS: From 193 cases of thyroid orbitopathy, eight cases (5%) of late reactivation were identified. The mean age of patients was 51 years (range 32-76 years) with a female to male ratio of 3:1. All cases presented with proptosis and seven demonstrated increased diplopia and gaze restriction. Signs of soft tissue inflammation were seen in three cases. All were euthyroid at presentation with a past history of thyroid orbitopathy and hyperthyroidism. One patient had an association of smoking with reactivation but the remainder had no discernible precipitants. The average interval between the initial orbitopathy and reactivation was 12 years (range 6-30 years). Computed tomography revealed enlarged extraocular muscles in seven cases and two showed partial response to treatment with low dose radiotherapy and steroids. The average length of disease activity was 14 months (range 9-18 months). CONCLUSION: Late reactivation of thyroid orbitopathy appears to be an uncommon phenomenon. It may occur under euthyroid conditions with no obvious precipitants and often presents as a reactivation of myopathy.

Adult↗
PubMed2001

Myasthenia gravis presenting as a unilateral abducens nerve palsy.

A 48-year-old man with no significant medical history presented to the emergency department of a large, urban, tertiary-care hospital complaining of double vision and unsteady gait. Physical examination was remarkable for an isolated, unilateral sixth nerve palsy. After comprehensive testing, a final diagnosis of myasthenia gravis was made. The patient's unsteady gait was a manifestation of sensory distortion from the diplopia and corrected when the patient closed his eyes. The presentation of myasthenia gravis as an isolated sixth nerve palsy is unprecedented in the emergency medicine literature.

Abducens Nerve Diseases↗
PubMed2000

Reconstruction of orbital fractures with dehydrated human dura mater.

PURPOSE: The best method for reconstructing the fractured orbital floor remains controversial. This article evaluates the usefulness of dehydrated human dura mater for orbital floor reconstruction after facial trauma. PATIENTS AND METHODS: A retrospective analysis of 55 patients who had undergone surgical repair of orbital fractures was performed. The dura mater was used when the disruption was less than 2 cm in diameter. Fractures were divided into 3 types: type I (blow-out), type II (orbitozygomatic fracture), and type III (midfacial fracture). The patients were followed-up at least 1 year after surgery, and the cosmetic and functional results were reviewed. RESULTS: A 7% complication rate was noted. No implant migration or infection resulted. One year postsurgery, all patients showed a complete resolution of their diplopia. CONCLUSION: The safety and biocompatibility of dehydrated human dura mater support its use in orbital defects less than 2 cm in diameter.

Accidental Falls↗
PubMed2000

Quantitative volume replacement in the correction of post-traumatic enophthalmos.

We describe a technique to correct enophthalmos that involves measurement of the volume of the injured orbit followed by an accurate replacement of this volume with an autogenous bone graft. Twelve consecutive patients were treated with this technique and all but one showed an improvement in enophthalmos. Four of the seven with diplopia improved after the operation.

Bone Transplantation↗
PubMed2000

Preplanned correction of enophthalmos using diced cartilage grafts.

A simple technique for correcting post-traumatic enophthalmos is presented. Autogenous costal cartilage was chopped into small pieces and used to fill up the medial orbital wall defect in five patients. The measured degrees of enophthalmos ranged from 2 to 4 mm, and 3-5. 5 ml of filler material was introduced into the periorbital space. A conservative approach via upper and lower eyelid incisions was used. It was found that 1.37-1.5 ml of graft material results in 1 mm advancement of globe position. This correlation appears to be a useful treatment guideline for medial orbital wall blow-out fractures. Transient diplopia developed in three cases, but settled within 4 months. There were no other major sequelae after the operation. The follow-up period ranged from 8 months to 3 years. The improved appearance and the stable results confirm the validity of this approach.

Adult↗
PubMed2001

Effectiveness of operative treatment of internal orbital wall fracture with polydioxanone implant.

Many implants, some made from teflon or silicone, have been used for internal orbital wall reconstruction. Late complications relating to use of such implants have been reported. In this prospective study a polydioxanone (PDS) implant absorbable in vivo was used for internal orbital wall reconstruction. Follow-up involved clinical examination, magnetic resonance imaging (MRI) and computerized tomography (CT). Clinical examinations were undertaken before operation and up to 36 weeks postoperatively. Sixteen consecutive patients (10 pure blow-out fractures, six with associated zygomatic fracture) took part in the study. Prevalences of diplopia, proptosis and enophthalmus were recorded during each follow-up examination. This study revealed no muscle entrapment within the fracture line. Although CT results confirmed bone growth in the internal orbital wall, shape was unsatisfactory, and orbital volume was not reduced. MRI revealed thick scar formations in six cases (37.5%), fibrotic sinuses filled with air or gas in three cases (19%) and a fibrotic sinus with fluid around the PDS in one case (6%). Our results suggest that use of PDS in reconstructing the internal orbital wall is inadvisable.

Absorbable Implants↗
PubMed2002

Cavernous sinus metastasis from thyroid papillary adenocarcinoma.

We report here an extremely rare case of cavernous sinus metastasis from thyroid papillary adenocarcinoma presenting long after initial diagnosis. A 41-year-old patient presented with a cavernous sinus tumor causing progressive diplopia 10 years after treatment for a papillary adenocarcinoma of the thyroid. After 5 years of close observation, subarachnoid hemorrhage developed from the cavernous sinus tumor extending to the cerebellopontine angle, at which point the patient underwent surgical removal of the tumor followed by gamma knife radiosurgery. The pathological diagnosis was papillary adenocarcinoma, indicating the distant metastasis from the thyroid. This case illustrates the unique event of a cavernous sinus metastasis long after initial treatment of the primary cancer.

Adenocarcinoma, Papillary↗
PubMed2000

Update on orbital floor fractures: indications and timing for repair.

There has been much discussion and controversy over the management of blowout fractures of the orbit. At various times, recommendations have included operating on all orbital floor fractures and operating on none of them. As our understanding of blowout fractures and their sequelae has evolved over time, so too has understanding of when and whom would benefit from surgery. In the past, the focus has often been on early versus late repair. The focus should really be on understanding the mechanisms of diplopia and enophthalmos in orbital floor fractures, the best way to evaluate a patient, and, finally, the best method of restoring maximal function and appearance. We present herein a historical perspective on the management of orbital floor fractures and our current recommendations for the indications and timing of surgical repair.

Diplopia↗
PubMed2001

[Orbito-palpebral emphysema due to ethmoidal fracture].

BACKGROUND: Orbito-palpebral emphysema is a frequent pathological entity due to head injury. We report on a patient and correlate the clinical view and computer tomography findings. CASE REPORT: A 17-year-old male was referred to our hospital after a blunt trauma to his head. Visual acuity was 1,0. Diplopia, restricted motility and exophthalmus about 4 mm were found. CONCLUSION: If swelling of the lid is found orbito-palpebral emphysema should be thought of to initiate appropriate therapy to avoid possible severe complications, for example, occlusion of the retinal central artery.

Adolescent↗
PubMed2002

[Ocular myasthenic syndrome and systemic lupus erythematosus].

BACKGROUND: Reports on association of systemic lupus erythematosus (SLE) and myasthenia gravis are sparse. CASE REPORT: An 40-year old woman complained of sudden onset of diplopia. A SLE was known for 6 years. Both eyes showed a deficit in upgaze, the right eye showed a deficit in abduction and a slight ptosis. Further ophthalmologic and neurologic status were normal. Magnetic resonance tomographic imaging of the brain and the results of the spinal fluid examination were unremarkable. Sonographic imaging and magnetic resonance tomographic imaging studies showed normal extraocular muscles. The edrophonium test (short acting inhibitor of acetylcholinesterase) was positive (elevation of the ptotic lid after injection of edrophonium). Acetylcholine receptor antibodies were elevated to 70 nmol/l (norm: < 0.25 nmol/l). Thoracic computed tomographic scan showed no evidence of a thymoma/thymus hyperplasia or thymus carcinoma. Systemic steroid treatment resolved the complaints within weeks. CONCLUSIONS: The patient with SLE had an ocular myasthenic syndrome. The etiology of the association of the two autoimmune diseases is not clear. SLE patients showing fatigue signs or pareses should be examined for myasthenia gravis. Patients with isolated ocular myasthenic syndromes should be examined for a generalized immunological disorder.

Adult↗
PubMed2003

[Retro-equatorial myopexy following Hummelsheim transposition in treatment of 6th cranial nerve paralysis].

INTRODUCTION: Vertical muscle transpositions are considered as the classic procedures for total VIth nerve palsy, whereas weakening of the controlateral medial rectus muscle requires a residual function of the paretic muscle. The aim of this study is to investigate the cumulative effects of these two different surgical approaches applied to the same patients. PATIENTS AND METHODS: 2 patients (M 48 years and F 55 years) with posttraumatic total VIth nerve paralysis were operated in two steps more than 1 year after trauma. The first procedure consisted of a Hummelsheim transposition of the vertical recti and was followed by a posterior fixation of the controlateral medial rectus. RESULTS: The vertical transposition resulted in the improved position of the paretic eye and in the disappearance of diplopia in primary position. The posterior fixation considerably improved the motility in abduction of the paretic eye and consequently provided the patients with widened binocular field of fusion. CONCLUSION: Posterior fixation of the controlateral medial rectus efficiently complements the vertical transposition in cases of total VIth nerve palsy. This combined effect remained stable during a 2 years follow-up in our patients.

Abducens Nerve Diseases↗
PubMed2003

[Development of ocular motility following modified 3-wall decompression of the orbita in endocrine orbitopathy for functional and rehabilitative indication].

INTRODUCTION: Permanent visual damage due to an increase in volume of the orbital contents may be the result of the failure of conservative therapeutic concepts in the treatment of endocrine orbitopathy. Considerable progress has been achieved in developing successful orbital decompression techniques with regard to functional and cosmetic outcome. Decompression techniques with resection of the bony orbital walls are adequate tools in restoring visual acuity and reducing exophthalmus. A considerable degree of deterioration of motility disorders has been described in the literature depending on the techniques being used. PURPOSE: The purpose of this study was to investigate whether a modified technique of 3-wall orbital decompression with preservation of a medial part of the periorbital tissue to support the medial rectus muscle, is able to reduce the postoperative risk of diplopia. MATERIAL AND METHODS: A modified technique of orbital 3-wall decompression with resection of the medial orbital wall, the medial orbital floor and the floor of the frontal sinus has been used in patients with compressive optic neuropathy (n = 20) and for cosmetic reasons (n = 7) in cases of uni- or bilateral proptosis. Analysis of the results was performed concerning visual outcome, exophthalmus reduction and development of horizontal and vertical motility changes. RESULTS: In all cases of optic neuropathy improvement of visual function at an average of 4.63 +/- 4.5 lines could be achieved. Exophthalmus reduction was 3.2 +/- 2.4 mm in the functional group and 3.9 +/- 1.7 mm in the rehabilitative group. In this group motility of the medial rectus muscle remained unaffected except in one eye. In the functional group motility deterioration was observed in 62 %. CONCLUSION: The modified 3-wall decompression technique with preservation of a medial periorbital tissue strip is an adequate alternative technique in the therapy of optic neuropathy and exophthalmus reduction in endocrine orbitopathy with a low risk of postoperative motility disorders.

Adipose Tissue↗