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PubMed1979

Orbital floor fractures--should they be explored early?

One hundred consecutive cases of orbital floor fractures from varying causes are reviewed, and the admission symptoms and signs are compared to the late results. We considered the early findings of diplopia, infraorbital rim step-off, and hypesthesia (with an associated clinical diagnosis of malar bone involvement) an indication for exploration of the orbital floor and possible placement of silicone sheeting. When this was done, minimal complications resulted.

Adolescent↗

PubMed1980

Superior oblique paresis after blepharoplasty.

A case of superior oblique paresis is presented which appeared to be due to cautherization of the superior oblique tendon. The torsional diplopia and head tilt were corrected with recession of the contralateral inferior rectus muscle.

Adult↗

PubMed2002

Trapdoor fracture of the orbit in a pediatric population.

Orbital-floor blowout fractures of the trapdoor variety, first described by Soll and Poley, have also appeared in the French and Japanese literature. The trapdoor fracture is described as a pure orbital-floor fracture, linear in form and hinged medially, which allows herniation of orbital contents through the fracture and then entraps these herniated contents. A review of the orbital-floor fracture literature reveals a high incidence of persistent diplopia associated with ocular-muscle entrapment, which may later necessitate corrective surgery of extraocular muscles. Recent publications in the ophthalmologic literature have stressed the importance of early surgical intervention. This article reports a retrospective series of 19 pediatric patients (age range, 5 to 16 years) who presented to two institutions. All patients had radiographic confirmation of a trapdoor fracture. Physical examination demonstrated a high association between these fractures and restricted ocular motility (17 of the 19 patients). In the cases with trapdoor fracture and restricted ocular movement, early intervention was associated with better postoperative function. It is thus recommended that the symptomatic trapdoor orbit fracture be considered an urgent indication for surgical intervention. Practitioners therefore must have a high index of suspicion for these injuries. Prompt diagnosis is critical to maximize clinical outcome.

Adolescent↗

PubMed2001

Choroidal infarction, anterior ischemic optic neuropathy, and central retinal artery occlusion from polyarteritis nodosa.

PURPOSE: Ocular ischemia from polyarteritis nodosa (PAN) is rare. The authors present a case of multifocal ocular infarction from PAN. METHODS AND RESULTS: A 70-year-old woman developed hand and foot numbness followed by intermittent blurred vision and binocular horizontal diplopia. Two weeks later, she suddenly lost vision in the right eye from a central retinal artery occlusion and then developed a left anterior ischemic optic neuropathy and bilateral triangular choroidal abnormalities consistent with infarction. Her erythrocyte sedimentation rate and C-reactive protein were elevated. Although giant cell arteritis was suspected, a multiple mononeuropathy was demonstrated by electromyogram and nerve conduction velocity studies. Biopsy specimens from her sural nerve and biceps muscle showed a necrotizing vasculitis with fibrinoid necrosis, consistent with PAN. CONCLUSIONS: Polyarteritis nodosa can produce ischemia of a variety of ocular structures, including the retina, choroid, and optic nerve. In our patient, all three structures were affected. To our knowledge, this is the first reported case of the triangular sign of Amalric in PAN.

Aged↗

PubMed1998

Compression of the upper cervical spinal cord causing symptoms of brainstem compromise. A case report.

STUDY DESIGN: A case is reported in which a flexion-induced compression of the upper cervical spinal cord caused symptoms of brainstem compromise in the absence of radiographic evidence of osseous instability. OBJECTIVES: A 41-year-old woman developed postoperative cervical instability with flexion-induced neurologic symptoms referable to the brainstem. The instability was caused by direct compression at the third cervical vertebral body, which in turn was caused by differential movements between the neuraxis and skeletal elements in the upper cervical spine. SUMMARY OF BACKGROUND DATA: Pathologic processes at the craniocervical junction may cause brainstem compromise with neurologic symptoms. The mechanism of brainstem involvement is usually either vertebrobasilar insufficiency or direct mechanical compression. In cases where the brainstem is compressed by skeletal elements, the compressing osseous structures usually are the walls of the foramen magnum or the odontoid process, or, less frequently, the atlas or axis vertebrae. Symptoms of brainstem dysfunction caused by dynamic compression at the level of the third cervical vertebra in the absence of hindbrain herniation are unusual and, to the best of the authors' knowledge, have not been described previously. METHODS: The patient underwent initial examination, evaluation, and periodic follow-up examination with magnetic resonance imaging from the time of her first visit until 26 months after the surgical treatment. The patient experienced postsurgical instability with dynamic compression by the C3 vertebral body, which caused brainstem compromise. Surgical treatment consisted of decompressive C3 corpectomy and fusion of C2 to C6, supplemented by anterior fixation. RESULTS: After undergoing surgical decompression of C3, reconstruction, and anterior internal fixation of C2 to C6, the patient had dramatic neurologic improvement. Diplopia, paresthesia, and nystagmus disappeared immediately after surgery. Swallowing difficulties, hoarseness, and vertigo improved gradually. At follow-up examination 26 months after surgery, the patient was asymptomatic. Magnetic resonance imaging showed good position of the construct, with no evidence of compression of the spinal cord or brainstem. CONCLUSIONS: Instability of the cervical spine may result in symptoms of brainstem dysfunction, even in the absence of hindbrain herniation. This instability is explained by the differential movement between the bony structures and neuraxis in the upper cervical region. Diagnosis and adequate management of this instability alleviates the neurologic symptoms and prevents possible hazardous complications.

Adult↗

PubMed2000

Third nerve palsy as the presenting manifestation of esthesioneuroblastoma.

A 52-year-old patient experienced unilateral third nerve palsy because of cavernous sinus involvement of biopsy-proven esthesioneuroblastoma. The patient experienced resolution of diplopia after surgical debulking of the tumor. Clinicians should be aware of the neuro-ophthalmologic manifestations of esthesioneuroblastoma.

Cavernous Sinus↗

PubMed2000

Myasthenia gravis with a paraneoplastic marker.

Ocular manifestations of myasthenia gravis are very common. Myasthenia gravis may be associated with lung carcinoma. Lambert-Eaton syndrome is also commonly associated with lung carcinoma and can have ocular manifestations. Overlap of these two entities has been described. The case of a patient with fatigable diplopia and ptosis 3 years after removal of a large-cell lung carcinoma is presented. Tests results for acetylcholine receptor binding and modulating antibodies were positive for myasthenia gravis. Test results for presynaptic voltage-gated calcium channel antibodies of the N-type were also positive. However, test results for the P/Q-type voltage-gated calcium channel antibodies, which are consistent with Lambert-Eaton syndrome, were negative. Autoantibodies can be used to serologically distinguish paraneoplastic myasthenia gravis from Lambert-Eaton syndrome.

Autoantibodies↗

PubMed2000

The spectrum of presentation of silent sinus syndrome.

The general clinical, ophthalmologic, and radiologic features of three patients with silent sinus syndrome are presented. All three patients were treated surgically. The cases of these patients illustrate the spectrum of presentation of silent sinus syndrome, including enophthalmos, hypophthalmos, transient vertical diplopia, lid retraction, lagophthalmos, and blurred vision. All patients had sinus disease, and all patients improved after surgery using functional endoscopic sinus surgery techniques. The protean manifestations of silent sinus syndrome can be identified, thereby allowing appropriate management.

Adult↗

PubMed2003

Surgical management of skew deviation.

There are no published data on the outcomes of realignment surgery for skew deviation. A retrospective chart review disclosed 10 patients who had undergone surgical correction of skew deviation by three surgeons at a single institution between 1991 and 2002. Nine of 10 patients had satisfactory relief of diplopia with an acceptable field of single binocular vision. Vertical rectus recession or resection was the most common procedure. Four patients required more than one procedure. For nonalternating hypertropias, resection of the inferior rectus muscle or recession of the superior rectus muscle of the hypertropic eye was successful. For alternating hypertropia, resection of both inferior rectus muscles was successful. Oblique muscle surgery was not associated with good outcomes.

Adult↗

PubMed2005

Multiple bilateral extraocular muscle metastases as the initial manifestation of breast cancer.

A 75-year-old woman had gradually progressive binocular diplopia and 2 months later had breast cancer diagnosed. Examination showed bilateral external ophthalmoplegia with lid retraction and lag and no pupillary abnormalities. Orbital magnetic resonance imaging showed enlargement and enhancement of all extraocular muscles bilaterally. A right orbital biopsy was consistent with metastatic breast carcinoma. Positron emission tomography, bone scan, and computed tomography of the chest, abdomen, and pelvis failed to disclose other evidence of breast cancer metastases. It is unusual to encounter metastatic breast cancer affecting every extraocular muscle before the diagnosis of the primary carcinoma.

Aged↗

PubMed2002

Thyroid and the eye.

Any thyroid cancer can metastasize to the uveal tract, even after decades; medullary thyroid cancer can be part of multiple endocrine neoplasia syndrome. Superior limbic keratoconjunctivitis and lagophthalmos are prognostic markers for more severe thyroid-associated ophthalmopathy (TAO). The restrictive ophthalmopathy of TAO may be associated with more sustained ocular hypertension and require topical therapy. Several new studies address the therapy of TAO, ranging from retrobulbar to oral to intravenous glucocorticoids, alone or combined with radiotherapy. Endonasal decompression of the posterior orbit can be done well for severe optic nerve compression; however, leaving the anterior orbital septum intact can minimize postoperative diplopia. Smoking increases the risk and relapse rate for ophthalmopathy. Thyrotropin receptor antigen on fibroblasts diffusely in the body is causative in TAO and pretibial myxedema with even increased urinary secretion of glycosaminoglycans. Corticosteroid-responsive patients show a sustained up-regulation of the Th1/Th2 profile.

Decompression, Surgical↗

PubMed2001

Abrupt-onset oculomotor paralysis: an endocrine emergency.

Pituitary apoplexy is a severe and potentially life-threatening condition that may be highly variable in its clinical presentation. We report a 37-year-old man presenting to the emergency department with diplopia that abruptly developed while he was eating canned and bottled food prepared at home. A computed tomography scanning revealed an isodense mass within the sellar region and, subsequently, a magnetic resonance imaging showed a pituitary apoplexy causing a compression of the right III and VI oculomotor nerves. There was no improvement with hydrocortisone therapy and the patient underwent a transsphenoidal excision of the mass with an uneventful course. Pituitary apoplexy may raise in the appropriate setting the suspicion of botulism. The abrupt-onset paralysis of oculomotor nerves has been described as the chief presenting sign of pituitary apoplexy in only few cases including this. A pathophysiology, differential diagnosis with botulism and other causes of multiple cranial nerve paralysis, and treatment are described.

Acute Disease↗

PubMed2005

Gaze-induced Desçemet's folds secondary to a primary pterygium.

PURPOSE: To report a case of gaze-induced Desçemet's folds secondary to a primary pterygium. METHODS: Interventional case report, chart review, and literature review. RESULTS: Slitlamp examination of a 49-year-old man showed Desçemet's folds in the left eye on extreme right gaze secondary to the restrictive effect of a primary pterygium. The folds correlated with increasing astigmatism documented on corneal topography and restricted ocular motility and diplopia on attempted adduction. CONCLUSIONS: To the authors' knowledge, this is the first reported case of folds induced in Desçemet's membrane secondary to the tethering effect of a primary pterygium.

Astigmatism↗

PubMed2005

Inflammatory myofibroblastic tumor of the orbit presenting as a subconjunctival mass.

PURPOSE: To present a case of inflammatory myofibroblastic tumor in the anterior orbit and to describe its clinical features, diagnosis, and management. METHODS: Case report and literature review. RESULTS: A 10-year-old boy presented with diplopia and limited ocular motility in his right eye secondary to a subconjunctival mass in the right supranasal side. Incisional biopsy and debulking were performed. Histopathologic examination showed the proliferation of spindle-shaped myofibroblasts that were immunoreactive for smooth muscle actin and vimentin and infiltrate of inflammatory cells. CONCLUSIONS: We believe this is the first case of an inflammatory myofibroblastic tumor found localized in the orbit.

Actins↗

PubMed2006

Intratumoral and brainstem hemorrhage in a patient with vestibular schwannoma and oral anticoagulant therapy.

OBJECTIVE: To report the first case of spontaneous intratumoral and brainstem hemorrhage in a patient with a vestibular schwannoma. STUDY DESIGN: Case report and review of the literature. SETTING: University-based, tertiary referral center. PATIENT: A 73-year-old woman with a vestibular schwannoma, anti-vitamin K overdose, and arterial hypertension experienced a rapid onset of headache, facial palsy, diplopia, and hoarseness. INTERVENTIONS: The patient was admitted to the intensive care unit and treated with vitamin K and corticoids. MAIN OUTCOME MEASURES: Clinical and radiologic findings. RESULTS: At admission, the magnetic resonance imaging and computed tomographic scans showed an intratumoral hemorrhage. The patient entered a coma 24 hours after the onset of the symptoms. At that time, the computed tomographic scan demonstrated a massive intratumoral and brainstem hemorrhage. The patient died 3 days later. CONCLUSION: Intratumoral, subarachnoid, and brainstem hemorrhages can occur in patients with vestibular schwannoma. Oral anticoagulant therapy is a risk factor for tumor-related hemorrhage.

Administration, Oral↗

PubMed2004

Temporal influences on retinal correspondence: ocular motor findings in paradoxical spatial projection.

BACKGROUND: Paradoxical diplopia is a condition in which objective eye position contradicts subjective localization in visual space. The term "paradoxical" is usually reserved for instances when known sensory adaptations cannot explain the contradiction. The development of this condition begins with infantile or childhood strabismus, followed by the development of a common sensory adaptation, anomalous retinal correspondence (ARC). ARC causes a reduction in the subjective angle of strabismus compared with the objective angle, and in its completed form the subjective angle decreases to zero. There is no "adaptive" mechanism that would increase the subjective angle such that it would be greater than the objective. In cases of treatment by corrective surgery, the anatomically based motor correction leads to a contradiction between eye position and binocular perception. In this event, the objective angle is less than the subjective, and the result is a paradoxical perception. We encountered a 25-year-old woman who experiences paradoxical localization on cover testing in the absence of a manifest strabismus and with no previous surgical intervention. METHODS: Using a magnetic search coil technique, we evaluated eye movements during fixation, smooth pursuit, saccades, and during cover test conditions to determine how these eye movements correlated to the subjective perception in space. RESULTS: Although smooth pursuit and saccades were normal, there were two elements during cover test that could explain the paradoxical projection. One was the phenomenon that during the cover test the paradoxical projection appeared only when the eye was covered for >4 s. The second was that there was a regression from the full exophoria position toward the midline while the eye was under cover that correlated with a possible paradoxical projection situation. DISCUSSION: ARC, usually associated with a beneficial sensorimotor adaptation, can express itself as a detrimental sensorimotor manifestation. Paradoxical perception also can exist without previous surgical intervention and without the influence of prisms and instrumentation such as the synoptophore. Further studies are indicated to explore the sensorimotor feedback mechanism between eye position and spatial perception.

Adult↗

PubMed2003

Acquired strabismus following cosmetic blepharoplasty.

The purpose of this study was to report on 12 patients with acquired strabismus following cosmetic blepharoplasty and to identify patterns of strabismus related to the surgical procedure. Clinical ophthalmologic examinations were performed to specifically clarify the type of strabismus. Operative reports of the blepharoplasty procedures were reviewed. Patients were followed for a minimum of 3 months after the blepharoplasty procedure before surgical intervention was considered. Operative findings at corrective strabismus surgery were noted and an attempt was made to correlate these findings with the clinical ophthalmologic examination and the blepharoplasty surgical procedure. Twelve cases of persistent vertical strabismus occurred following blepharoplasty procedures. Five patients had clinical findings consistent with the diagnosis of acquired superior oblique palsy; one of these five patients also showed signs of an acquired Brown syndrome. Seven patients developed an incomitant vertical deviation consistent with an inferior rectus paresis. Strabismus occurred after conventional lower lid, upper lid, and four-lid blepharoplasty with or without laser blepharoplasty. Acquired strabismus accompanied by persistent diplopia may occur as a complication of cosmetic blepharoplasty. Extraocular muscle damage resulting in either superior oblique muscle palsy or inferior rectus paresis was noted in these patients. In some cases, patients with inferior rectus paresis also showed mechanical restriction to upward rotation of the globe.

Blepharoplasty↗

PubMed2006

Individual CAD/CAM fabricated glass-bioceramic implants in reconstructive surgery of the bony orbital floor.

BACKGROUND: The aim of the study was to present a set of preliminary cases from an ongoing program of reconstructive procedures using a new technique in the treatment of severe enophthalmos and diplopia after the primary treatment of orbital floor fractures had rendered insufficient results. METHODS: Glass-bioceramic implants were shaped from computed tomography coordinates with computer-assisted design and computer-assisted manufacturing. In this prefabrication process, the implants were milled individually out of a solid block of Bioverit II (3di Gmbh, Jena, Germany). The adequacy of this reconstruction for treating malfunction and aesthetic deficits was evaluated. RESULTS: Eight patients with orbital floor fractures underwent successful surgery. The results were encouraging, with all patients showing a good functional and aesthetic outcome. CONCLUSIONS: Computer-assisted design/computer-assisted manufacturing implants made of Bioverit II can be used for a very accurate and successful secondary reconstruction of the orbital floor. However, it addresses only a few aspects of the treatment of orbital floor fractures and should be considered as an equal alternative to other reconstruction methods.

Adult↗