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PubMed2005

Late enophthalmos mimicking silent sinus syndrome secondary to orbital trauma.

The authors present a retrospective case report of a patient who experienced late enophthalmos after blunt orbital trauma. A 27-year-old man presented with subacute onset of enophthalmos, hypoglobus, superior sulcus deformity, and computed tomography evidence of a collapsed maxillary sinus 6 months after sustaining an ipsilateral moderately displaced orbital floor fracture. He was taken to surgery for left endoscopic maxillary antrostomy and implantation of an alloplastic orbital floor graft. Two months after surgery, the patient's diplopia, enophthalmos, hypoglobus, and superior sulcus deformity were markedly improved. Reestablishment of maxillary sinus aeration, the orbital floor, and the medial wall successfully relieved the symptoms and signs of maxillary wall implosion. The mechanism of this rare condition, which shares features similar to silent sinus syndrome, is presented.

Adult↗
PubMed2005

Long-term outcomes of ultra-thin porous polyethylene implants used for reconstruction of orbital floor defects.

PURPOSE: The objective of this article is to present the long-term outcomes of ultra-thin polyethylene implants used for orbital floor reconstruction in facial trauma patients. MATERIALS AND METHODS: From 1998 to 2004, 38 patients underwent orbital floor reconstruction with porous polyethylene implants with a mean follow-up of 4 years. A subciliary incision and preexisting facial wounds or scars were used. The boundaries of the maxillofacial injury and the orbital volumes of both orbits were assessed by computed tomography images obtained pre- and postoperatively. In all patients, ultra-thin porous polyethylene implants in various sizes were used to reconstruct the orbital floor defect. RESULTS: None of the patients needed removal of the implants during the follow-up. The volume increase of the traumatized orbits ranged from 0.04 to 6.18 (average 3.12 +/- 1.48) mL compared with the intact orbit (P < 0.01). This difference was not significant postoperatively (P > 0.01). Postoperative ectropion in three cases was corrected under local anesthesia. Persistence of complications were as follows: enophthalmos, 3 in 28; diplopia, 1 in 16; dystopia, 1 in 4; and infraorbital nerve hypoesthesia, 3 in 31. One patient underwent late enucleation of the globe because of initial penetrating trauma. CONCLUSIONS: We recommend the use of ultra-thin porous polyethylene implants in the reconstruction of the orbital floor defects in facial trauma patients. The implants are durable in the long-term and mimic the anatomy of the thin orbital floor and avoid the morbidity of autogenous bone grafts.

Adult↗
PubMed2005

Primary melanoma of the sphenoid sinus presenting with a third cranial nerve palsy.

An 83-year-old woman presented with right trigeminal paresthesias, upper lid ptosis, and diplopia and was found to have a right third cranial nerve palsy. MRI disclosed a right sphenocavernous mass with speckled high signal on pre-contrast T1 and correspondingly low signal on T2. Endoscopic sphenoidotomy revealed malignant melanoma. The patient underwent radiation therapy with complete and protracted resolution of the palsy. An extensive evaluation for a primary source was negative. The combination of high T1 signal and low T2 signal in a mass should suggest melanin. An exceedingly rare condition, this is the first English report of its presentation with a third cranial nerve palsy.

Aged, 80 and over↗
PubMed2005

Ophthalmic manifestations in 18 patients with botulism diagnosed in Porto, Portugal between 1998 and 2003.

BACKGROUND: Botulism is a rare but potentially lethal disease in which ophthalmic signs and symptoms are among the very earliest manifestations. The aim of this study was to investigate the epidemiological and clinical features of botulism-infected patients admitted to a general hospital in Porto, Portugal. METHODS: We performed a retrospective chart review of all botulism patients admitted to São João Hospital between January 1998 and January 2003. We excerpted data on epidemiology, ophthalmic and non-ophthalmic manifestations, and treatment. RESULTS: We identified 18 patients in nine registered outbreaks. In two patients (11%), ophthalmic manifestations preceded systemic manifestations; in six patients (33%), ophthalmic and systemic manifestations occurred simultaneously; in ten patients (56%), systemic manifestations occurred first. Ophthalmologists had examined only seven patients and made the correct diagnosis in five. The most common ocular symptoms were blurred near vision (100%), blurred distant vision (94%), and diplopia (44%). Accommodation impairment was documented in all seven patients examined by ophthalmologists. CONCLUSIONS: Ophthalmic manifestations were among the earliest and most prominent manifestations of botulism in this series, as in earlier reports. The diagnosis should be suspected when impaired accommodation and gastrointestinal symptoms occur together.

Accommodation, Ocular↗
PubMed2006

Invasive fungal sinusitis of isolated sphenoid sinus in immunocompetent subjects.

Invasive fungal sinusitis of the paranasal sinuses in a healthy immunocompetent person is uncommon. Isolated involvement of any paranasal sinus, particularly sphenoid sinus is rare. In this study, five immunocompetent patients who had no nasal complaints but obscure symptoms of headache and orbital symptoms such as diplopia, retro-orbital pain and loss of vision were diagnosed to be having fulminant fungal sinusitis of the sphenoid sinus. Three patients had aspergillosis and two patients had mucormycosis. These patients initially presented to neurologists and ophthalmologists because they had no ENT complaints. The diagnosis was made on endoscopy, radiology and histopathology. They were treated aggressively according to the standard protocols. The purpose of this paper is to bring to light the changing clinical spectrum of invasive fungal sinusitis. It can occur in immunocompetent patients and in the form of isolated sphenoid sinus involvement.

Adolescent↗
PubMed1988

Management of dysthyroid eye disease.

Once the diagnosis of thyroid eye disease has been made the doctor's problems begin because the management is long term with a condition that has many ramifications over a period of years. Short-term heroics to save vision by use of high-dose systemic steroids, orbital decompression or radiotherapy may have to be followed by control of diplopia by muscle surgery and prisms. Lid retraction, both upper and lower, may merit surgery, and even those patients who have come to terms with their facial appearance may still complain of lacrimation, irritation and grittiness. The advantages of a thyroid clinic, run jointly by a physician and an ophthalmologist, are presented and the patient is helped to live with this distressing condition.

Adult↗
PubMed1989

Early and late botulinum toxin treatment of acute sixth nerve palsy.

Ten patients with sixth nerve palsy were treated with botulinum toxin injection to the antagonist nonparetic medial rectus. All patients were followed for a minimum of 14 months after the last injection. Six patients were treated within eight weeks of the onset of the palsy. Within a few days five of the six gained fusion, without the necessity of a marked head turn and none complained of confusing reversal of diplopia. The same five recovered full function. Four patients with no medial rectus contracture on forced duction testing were treated six months or longer after the onset of the palsy and none recovered full function. One of the four patients was permanently over-corrected despite persistent weakness of the lateral rectus. This preliminary report suggests that early botulinum toxin injection of patients with recent onset (acute) sixth nerve palsy is beneficial. Since some patients may recover spontaneously a randomised double-blind study is necessary to more precisely determine the effectiveness of this form of therapy. Botulinum toxin does not appear to be effective in facilitating recovery in those cases with poor lateral rectus function six months or longer after the onset of the palsy, even when there is no contracture of the medial rectus.

Abducens Nerve↗
PubMed1998

The Heimann-Bielscholwsky phenomenon: dissociated vertical nystagmus.

BACKGROUND: The Heimann-Bielschowsky phenomenon (HBP) is a unilateral vertical nystagmus with coarse, slow pendular movements that typically occurs in an eye with profound visual loss. There are no sinister neurological implications. METHODS: Symptoms and signs on presentation and the subsequent course are described in detail in 10 patients. Eye movements were recorded for one patient. RESULTS: Three patients had corrected vision of 6/24 or better. Strabismus was seen in eight patients. Symptoms of diplopia and oscillopsia were infrequent. CONCLUSIONS: We believe that the HBP may be a reasonably common condition, although very under diagnosed. This condition may be similar to Central Fusion Disruption. Patients with HBP appear to have lost the potential for fusion.

Adolescent↗
PubMed1998

Inferior rectus rupture following blowout fracture.

BACKGROUND: Extra-ocular muscle rupture is uncommon, usually seen after penetrating trauma or surgery. It is a very rare cause of diplopia following blunt orbital trauma. METHODS: A patient who presented with no inferior rectus function after blunt orbital trauma is described. RESULTS: Computed tomography (CT) scans demonstrated a large orbital floor fracture and suggested that the inferior rectus muscle was ruptured. This was confirmed at operation. Despite anatomical repair, there was no postoperative improvement in ocular motility. CONCLUSIONS: Traumatic rupture of the inferior rectus is rare. Forced duction and force generation testing and CT are important in diagnosing ocular motility defects following orbital trauma.

Adult↗
PubMed2004

'Ancient' schwannoma of the orbit.

A 65-year-old woman presented with a 3 month history of right eye discomfort and protrusion. Examination revealed right proptosis with hypoglobus and diplopia in extremes of upgaze. Computed tomographic scanning revealed a large extraconal mass in the superotemporal orbit. The mass was excised through an extended superior skin crease incision. Histopathology revealed a benign tumour of Schwann cell origin showing advanced cystic degeneration, the so-called 'ancient schwannoma'. The authors could find only two previously reported cases of such tumours arising in the orbit.

Aged↗
PubMed2005

Skew deviation: a precursor to basilar artery thrombosis.

The aim of this study was to describe skew deviation and vertical nystagmus as the initial signs for basilar artery thrombosis, a life-threatening disease. A 51-year-old woman complained of vertical diplopia for more than 20 h. A computed tomography of the brain was normal, but subsequently the patient developed additional symptoms including nausea, ventilation problems (dyspnoea) and somnolence. Neuro-ophthalmological evaluation revealed a skew deviation and a vertical nystagmus. Magnetic resonance imaging allowed the diagnosis of basilar artery occlusion. An emergency intervention with cerebral catheter angiography and local intra-arterial thrombolysis was performed. Total recanalization of the basilar artery was achieved resulting in a complete neurological recovery, including the skew deviation and nystagmus. This rare case of skew deviation associated with basilar artery occlusion was a diagnostic challenge and highlights adequate differential diagnosis. Skew deviation is an important clinical sign. In this patient it was the key to a correct diagnosis enabling an immediate and successful intervention.

Cerebral Angiography↗
PubMed2004

Circinate corneal scarring.

A 56-year-old man presented with symptoms of monocular diplopia and reduced vision in his left eye. Visual acuities were R6/6, L6/12. At his previous visit left visual acuity was 6/6. An irregular area of anterior corneal stromal scarring was evident, encroaching on the visual axis of the left eye. Rigid lens fitting improved left visual acuity to 6/6, however, lens wear caused a corneal abrasion over the lesion after one to two hours of wear. Several other contact lens and surgical strategies were employed to successfully address the visual requirements of the patient.

Cicatrix↗
PubMed1984

Diurnal fluctuations in free and total steady-state plasma levels of carbamazepine and correlation with intermittent side effects.

The relationship between diurnal fluctuations in free (unbound) and total plasma carbamazepine levels and the appearance of intermittent side effects was investigated in nine epileptic patients receiving chronic therapy with carbamazepine, alone or in combination with phenobarbital. On a three-times-daily or four-times-daily dosing schedule, both total and free carbamazepine levels fluctuated considerably (on an average, 41 and 45%, respectively, around the mean). Side effects (particularly diplopia and nystagmus) were observed in five patients and showed an intermittent pattern in four. Side effects were never found at total carbamazepine levels less than 34 mumol/L but invariably appeared at levels greater than 38 mumol/L. At levels between 34 and 38 mumol/L adverse effects were inconsistently observed. The correlation between plasma carbamazepine levels and manifestations of toxicity was slightly stronger when free rather than total levels were considered. Side effects were always apparent at free levels greater than 7.2 mumol/L. These data underline the limitations of relying on a single drug level determination during the monitoring of carbamazepine therapy and emphasize the necessity of carefully adjusting the dosing schedule, to minimize the appearance of intermittent adverse effects.

Adolescent↗
PubMedDate not supplied

Epileptic nystagmus.

Two cases of epileptic nystagmus (EN) are described. The first patient had no history of seizures and experienced attacks of EN associated with oscillopsia and followed by horizontal diplopia and esotropia. These episodes could be triggered by certain visual stimuli and ocular pressure. The second patient had a history of generalized tonic-clonic seizures. He displayed episodes of EN that changed direction in the course of the attacks simultaneously with a shift of the EEG discharge from one occipital region to the other. Cortical blindness followed postictally. On recovery from the postictal state, both patients were neurologically normal. With standard electrodes, the EEG seizures associated with EN involved the occipital, posterotemporal, and parietal areas of the scalp contralateral to the fast phase of the nystagmus. In the first patient, use of supplementary scalp electrodes further localized the seizures to an anterior occipital site intermediate between standard occipital and posterotemporal electrodes. Thirty-six previously reported cases of EN were associated with partial seizures. Horizontal EN most commonly results from seizure activity involving the occipital cortex, although participation of adjoining portions of the parietal and temporal cortexes is possible.

Adult↗
PubMed1998

Carbamazepine toxicity with lamotrigine: pharmacokinetic or pharmacodynamic interaction?

PURPOSE: To determine whether the toxicity that occurs in some patients when lamotrigine (LTG) is added to carbamazepine (CBZ) is the result of either a pharmacokinetic or a pharmacodynamic interaction. METHODS: Escalating LTG doses were added to ongoing CBZ treatment in 47 patients. All patients had blood samples collected for drug concentration measurement, including the epoxide metabolite of CBZ, before starting LTG treatment and after stabilising at each dose escalation. Patients also were examined for signs of toxicity. RESULTS: After LTG was introduced, nine patients demonstrated clinical signs of CNS toxicity, mainly diplopia and dizziness. There was no significant (p = 0.05) change in the serum concentrations of either CBZ or its epoxide metabolite when LTG was added either to the group as a whole or to the nine patients who experienced adverse CNS effects. LTG serum concentrations also were below the level at which the common signs of LTG toxicity, such as nausea, vomiting, or unsteadiness, are more likely to occur. In seven of the nine patients who exhibited CNS toxicity, CBZ serum concentrations were >8 mg/L on LTG introduction. CONCLUSIONS: Toxicity is more likely to occur when LTG is added to CBZ if the initial CBZ level is high, typically >8 mg/L. This appears to be the result of a pharmacodynamic interaction. A reduction of CBZ dose usually resolves the toxicity, allowing the LTG dose to be escalated to maximal effect. It is not usually necessary to stop either drug.

Anticonvulsants↗
PubMed1990

Orbital CT in the management of blow-out fractures of the orbital floor.

The CT-examinations of 15 patients with blow-out fractures of the orbital floor were reviewed. All patients were examined with coronal/semicoronal CT-imaging, and 7 patients also were evaluated with semisagittal projections. Only in one case the semisagittal images gave more information than coronal sections when using the classification of Gilbard et al. (1985) of the inferior rectus muscle/fracture relationship. The anterior and posterior fracture margins were better delineated with semisagittal imaging. Two patients exhibiting positive traction tests with hooked, and not entrapped muscles on CT still had diplopia 5 1/2 and 12 weeks after the trauma.

Adolescent↗