Ophthalmic emergencies

Ocular emergencies can be very intimidating for veterinarians. Most ocular emergencies can be stabilized by the veterinarian until an ophthalmologist can be consulted if necessary. Proptosis, or forward displacement of the globe, can occur secondary to any blunt trauma to the head. The two options for a proptosed eye are enucleation or replacement with tarsorrhaphy depending on the viability of the extraocular tissues and eye. Glaucoma, or increased intraocular pressure (above 35 mm Hg), is diagnosed by measuring the intraocular pressure using a Shiotz or electronic tonometer. Emergency treatment includes intravenous mannitol and topical pilocarpine. Uveitis, or inflammation of the iris, ciliary body and/or choroid, can have many underlying causes such as neoplasia, infection, lens induced, and trauma. The treatment consists of treating the underlying cause, and administering topical atropine to alleviate pain and topical corticosteroids to decrease inflammation. Corneal ulcers, or defects in the corneal epithelium, are classified according to the depth of the defect. The treatment consists of topical antibiotics and topical atropine. If the ulcer is deep, is melting, or is a descemetocele, then a third eyelid or conjunctival flap is usually necessary. The cornea should be sutured if it is perforated or lacerated. Hyphema, or blood in the anterior chamber, can occur secondary to trauma, neoplasia, infection, or a coagulapathy. The treatment consists of treating the underlying cause and topical corticosteroids with or without antibiotics.

Bilateral orbital hemorrhage in a newborn

PURPOSE

To report a case of severe bilateral proptosis resulting from orbital hemorrhage in a newborn and to discuss the differential diagnoses and management.

METHOD

Case report of a 13-day-old male infant with bilateral proptosis since birth. The proptosis was monitored with clinical examinations and computed tomography as well as magnetic resonance imaging (MRI) scans, and it was managed with antibiotic ointment and patching. The MRI scans demonstrated bilateral subperiosteal orbital hemorrhage.

RESULTS

Proptosis decreased, and there was successful, complete recovery without untoward sequelae in 14 days; follow-up indicated no late complications at age 1 year.

CONCLUSION

Spontaneous orbital hemorrhage, unilateral or bilateral, is uncommon in an otherwise healthy newborn without apparent history of birth trauma. Magnetic resonance imaging scans are helpful in making the diagnosis of subperiosteal hemorrhage, and conservative management is advised.

[Exophthalmos--what now?]

Exophthalmos is most commonly due to Graves' ophthalmopathy (GO), the most frequent extrathyroidal manifestation of Graves' disease. The clinical signs and symptoms of GO are the consequences of increased orbital connective and adipose tissue volume, and of interstitial enlargement of extraocular muscles, within the confines of the bony orbits. Diagnosis of GO is usually readily established by obtaining a careful history, detailed clinical examination of the thyroid gland, eyes and orbits, few laboratory tests and ultrasonography of the thyroid gland and the orbital contents. Additional procedures such as computed tomography or magnetic resonance imaging are rarely needed. A team approach (general practitioner, endocrinologist, ophthalmologist) is essential to assure state-of-the-art management of patients with GO, and to properly select the best choices from a still limited range of therapeutic options.

Thyroid eye disease

Thyroid eye disease is the most common cause of unilateral and bilateral proptosis in adults. It occurs most frequently in women aged 30 to 50 years. Clinical features include eyelid retraction, periorbital edema, conjunctival injection and chemosis, proptosis, extraocular muscle restriction, exposure keratopathy, and optic nerve compromise. Thyroid eye disease differs from idiopathic orbital myositis in that the latter is characterized by a more acute onset, more severe pain, and a rapid response to systemic corticosteroid therapy. Echography and computed tomography in thyroid eye disease reveal enlarged extraocular muscle bellies with relative sparing of the tendons. Despite evidence of an immune-mediated cause, the precise pathophysiologic mechanisms of thyroid eye disease remain unknown.

[Digital subtraction angiography of cerebrum for diagnosis of cavernous sinus fistula and its intravascular treatment]

OBJECTIVE

To evaluate the diagnosis of digital subtraction angiography (DSA) of cerebral arteries and the intravascular treatment for carotid artery-cavernous sinus fistula (CCF) mainly manifesting as pulsating exophthalmos.

METHODS

Digital subtraction angiography (DSA) of cerebral arteries was carried out for 15 patients with pulsating exophthalmos. Of them, detectable balloon and tungsten filament microcoil were used for intravascular embolism treatment in 12 cases, and the 3 cases with CCF of the branch of external carotid artery were not treated.

RESULTS

Of the 15 cases, 12 were fallen in the CCF of high flow type of unilateral internal carotid artery, and 3 in the CCF of low flow type of unilateral external carotid artery. The symptoms and signs of intravascular embolism disappeared after treatment in 11 cases.

CONCLUSION

Cerebral artery DSA and intravascular therapy are the ideal methods for the diagnosis and treatment of CCF mainly manifesting as pulsating exophthalmos.

Unilateral proptosis and chemosis caused by dural arteriovenous malformation of the superior sagittal sinus

We describe a patient with unilateral proptosis and chemosis resulting from a dural arteriovenous malformation (AVM) of the superior sagittal sinus (SSS) fed mainly by branches of both external carotid arteries. The symptoms may have been caused by increased SSS pressure and disturbance of venous flow by the dural AVM.

Intravenous immunoglobulin versus corticosteroid in treatment of Graves' ophthalmopathy

We compared the effectiveness of systemic corticosteroids with the use of high-dose intravenous immunoglobulin (IVIG) in the treatment of Graves' ophthalmopathy. This was performed as a prospective, nonrandomized study including a blinded ophthalmological and orbital computed tomographic (CT) evaluation. The two groups of patients were not significantly different in relation to sex composition, age distribution, duration of Graves' disease, and ophthalmopathy and previous hyperthyroidism. All patients were followed up by endocrinologic evaluation and blinded ophthalmological (before therapy = B, at the end of therapy = E, and 6 months after the end = 6M) and orbital CT (B and E) evaluations. Twenty-seven patients treated with IVIG were followed up after the end of treatment for an average of 21 months (range 12 to 48 months). Soft tissue involvement (NOSPECS) improved or disappeared in 32 of 35 (90%) patients treated with IVIG and in 25 of 27 (92.5%) patients treated with corticosteroids. Diplopia improved or disappeared in 22 of 29 (75%) patients treated with IVIG and in 16 of 20 (80%) patients treated with corticosteroids. The results observed by clinical evaluation were confirmed with orbital CT score in 30 IVIG patients and in the corticosteroid-treated patients; a significant reduction of extraocular muscle thickness was observed after treatment in both groups. Proptosis improved or disappeared in 20 of 31 (65%) patients treated with IVIG and in 15 of 24 (62%) patients treated with corticosteroids. Mean values of proptosis evaluated by Hertel's exophthalmometer showed a slight reduction both in IVIG as well as in corticosteroid-treated patients. It is interesting to observe that in 28 IVIG-treated patients in whom it was possible to evaluate soft tissue involvement, proptosis and diplopia in the period between the fifth and sixth month from the start of therapy, the most important part of the amelioration (if responders) was already obtained at that time. Responder patients were defined in relation to the decrease in the highest NOSPECS class or grade. Among IVIG-treated patients 26 of 34 (76%) responded; while in the corticosteroid group 18 of 27 (66%) responded to treatment. The prevalences of patients who responded to the treatments were not significantly different in the two groups (Chi-square). The initial values of the subjective eye score were similar in the two groups, and a significant reduction was observed in both. Major side effects requiring discontinuation of the corticosteroid therapy were observed in two patients with hemorrhagic gastritis and in one patient with manic-depressive psychosis. Among 15 patients submitted to the evaluation of bone mineral content before and after corti-costeroid therapy, 4 presented signs of osteoporosis and 3 a reduction of bone mineral content. Moderate and minor side effects were more frequently noted in steroid-treated patients than in the IVIG group. These data suggest that IVIG is safe and effective in reducing the eye changes in patients with Graves' ophthalmopathy.

High-dose intravenous steroid pulse therapy in thyroid-associated ophthalmopathy

To evaluate the efficacy of high-dose intravenous steroid pulse followed by oral steroids in the treatment of thyroid-associated ophthalmopathy, we performed clinical assessment and measurement of retroorbital muscle enlargement in 27 patients before and after the therapy, and followed them up longitudinally. The mean duration of follow up is (mean +/- SD) 29.8 +/- 23.8 months (range 4-92). Diplopia disappeared in 10 patients and ameliorated in 11 patients. The degree of proptosis decreased in 15 patients and the fall in visual acuity improved in a third of the patients. The total ophthalmopathy index (OI) decreased from 7.0 +/- 1.9 to 3.0 +/- 1.5. The extraocular muscle enlargement (EME), expressed as the maximal ratio of extraocular muscle thickness to the diameter of the optic nerve, decreased from 2.33 +/- 0.56 to 1.27 +/- 0.26. No major side effects were found in any patient. The improvement in the eye disease was found immediately after the pulse therapy, prior to the start of the following therapy by oral steroids and/or orbital irradiation. Both of OI and EME decreased with time after the therapy and did not get worse after withdrawing oral steroids. The efficacy of the therapy evaluated by degrees of improvement in OI and in EME was significantly greater in females than in males. Although there was a significant positive correlation between initial OI and EME values and initial TBII and TSAb activities, a significant correlation was seen only between the degrees of improvement in EME and changes in TBII activity due to the therapy. The duration of eye disease, thyroid status, treatment with anti-thyroid drug, smoking and experience of previous treatment did not affect the efficacy of the present therapy. We conclude that high-dose intravenous steroid pulse therapy is effective and safe for thyroid-associated ophthalmopathy.

Luxation of the globe and Crouzon's disease--the first reported case in Singapore

A case of spontaneous luxation of the globe and Crouzon's disease is described. The luxation was reduced under general anaesthesia. Bilateral permanent tarsorrhaphies were performed to prevent further luxations and to decrease the lagophthalmos and corneal exposure. There was also mild bilateral optic atrophy and a left superior oblique palsy. The patient exhibited turricephaly, maxillary hypoplasia and shallow orbits with proptosis. Major reconstructive surgery is not indicated as the patient is already 9 years old and has no mental impairment.

Cystic lesions of the extraocular muscles

Cystic lesions of the extraocular muscles (EOMs) are uncommon. Six patients with a cystic lesion in an extraocular muscle, as observed by computerized tomography (CT) scanning, were retrospectively identified from the practice of one of the authors (G.C.S.), and their clinical course was reviewed. All the patients were treated initially with oral corticosteroids. Those who did not respond to this therapy underwent surgical exploration. Four patients demonstrated complete resolution of clinical signs and symptoms with oral steroid therapy. Posttreatment CT scans performed in two of these patients showed resolution of the cystic lesion with residual muscle thickening in one. The two patients not responding to steroids underwent surgical excision and histopathology confirmed the diagnosis of cysticercosis. Cysticercosis is a previously reported cause of a cystic lesion in an EOM. To the best of our knowledge, cystic lesions of the EOMs resolving with steroids have not been previously reported. Response to oral steroids in four of our patients is suggestive of myositis with a cystic change in the muscle. We recommend a trial of oral steroid therapy in patients with a cystic EOM lesion before surgical exploration is performed.

Aetiology and management of proptosis in young Jordanians

Sixty-two cases of proptosis in children and adolescents were prospectively evaluated in a specialized practice at Irbid, North Jordan, during the period between 1990 and 1994. Inflammatory orbital conditions were seen in 27 patients (43.5%). The causes of orbital cellulitis were identified in 15 out of 25 cases. Predisposing factors and outcome were analyzed. Vasculogenic lesions were encountered in 15 cases, five of which were subperiosteal orbital haematomas. Twelve cases with structural lesions ranging from a benign cystic dermoid to craniostenosis were managed in various ways. A rare case of primary hydatid disease in the orbit was also seen. Results of surgical treatment and outcome in each condition were assessed. Eight cases (14%) were neoplastic in nature. A rare case of retinoblastoma which presented as orbital cellulitis is included. Orbitotomies were performed for excision biopsy, mass removal and decompression or exenterations of the orbit, with no serious complications. No cases of proptosis owing to thyroid ophthalmopathy or systemic diseases were seen. The relatively low frequency of secondary orbital retinoblastoma among Jordanian children is compared with that in related reports from other countries.

Traumatic bilateral carotid-cavernous fistulas treated with detachable balloon. A case report

A 29-year-old male developed ptosis and progressive pulsating protrusion of the right eye, accompanied by conjunctival injection and tinnitus following a bicycle accident. MR angiography revealed dilation of both superior ophthalmic veins and facial veins. Right internal carotid angiography demonstrated right carotid-cavernous fistula (CCF) at the C3 portion of the right internal carotid artery with abnormal venous drainage. After right carotid balloon occlusion test had been performed, a detachable balloon was introduced into the right CCF while preserving the lumen of the right internal carotid artery. A left CCF, which was detected after closure of the right CCF, was also closed with a detachable balloon. Follow-up carotid angiographies showed complete closure of both CCFs and no abnormal venous drainage. After 1 year no abnormal physical manifestations, or abnormal neurologic signs or symptoms were present.

History and clinical signs. Bilateral exophthalmos, and left lagophthalmos and corneal ulceration

Images

Orbital pseudotumor as a presenting sign of temporal arteritis

Both unilateral proptosis (2 cases) and radiological evidence of orbital inflammatory pseudotumor in the absence of exophthalmos (1 case) have been separately described as presenting signs of temporal arteritis. We report a patient presenting with bilateral exophthalmos associated with CT and MRI signs of orbital inflammation, who had biopsy-proven temporal arteritis. Our case is unique in view of the association of the above clinical and radiological features, and the bilateral involvement of orbital tissues.

Proptosis as the initial presentation of fungal sinusitis in immunocompetent patients

BACKGROUND

Fungal sinusitis typically occurs in immunocompromised patients. The authors report four cases of fungal sinusitis in immunocompetent young adults, all of whom had proptosis.

METHODS

The diagnosis in all four patients was determined after orbital imaging and sinus biopsies.

RESULTS

All four patients required surgical removal of the fungal source and anti-fungal chemotherapy postoperatively.

CONCLUSION

Patients with proptosis, ocular pain, or other symptoms suggestive of orbital cellulitis unresponsive to antibiotic treatment should undergo radiographic imaging. If sinus disease is present, biopsy and culture may lead to the diagnosis of fungal disease. Surgical debridement and the appropriate systemic antifungal therapy usually lead to cure.

[Embryonal rhabdomyosarcoma of the orbit]

The paper shows the case of a 19-years-old patient, who presented two month before the observation took place marked exophthalmos at the left eye with general state alteration. Computerised tomography pointed out a tumoral formation having 4 centimeters in diameter, which pushed off the anterior ocular globe, eroding to the left frontal lobe. The anatomopathological exam evidenced the embryonal rhabdomyosarcoma. So, every unilateral exophthalmos of the child or teenager must lead the diagnosis of embryonal rhabdomyosarcoma. The therapy consists of exeresis biopsy, followed by complex radiotherapy and chemotherapy. The orbital exenteration, a multilant intervention, does not guarantee for the further evolution of the affection.

Malignant exophthalmos associated with multiple myeloma

We report a patient with malignant exophthalmos associated with multiple myeloma which showed no evidence of direct orbital involvement of plasma cells. This exophthalmos had similarities with Graves' ophthalmopathy, but the patient had no detectable autoimmune thyroid diseases. Plasmapheresis was effective not only for the treatment of heart and renal failure due to the myeloma kidney but also for the malignant exophthalmos. As the serum monoclonal IgG level was decreased by plasmapheresis, the improvement of proptosis, visual acuity, and hypertrophy of the extraocular muscle as measured by magnetic resonance imaging were observed. It is suggested that humoral factors removed by plasmapheresis might be involved in the pathogenesis of this nonendocrine exophthalmos.

Proptosis: management of 22 patients

The clinical features and management of 22 cases with proptosis is highlighted. Proptosis was unilateral in fifteen and bilateral in seven cases. The common etiologic factors were neoplasms, infections and bleeding diatheses. Of the ten cases with neoplasms as many as 7 expired, whereas of nine cases due to infections only one expired and one developed phthisis bulbi. All three patients with proptosis due to bleeds recovered completely without sequelae. Orbital CT scan was done in fourteen and ultrasound in eight cases, while in five cases both investigations were done. As neoplasms are a frequent cause of proptosis in children and there is a high mortality in this group, a thorough systemic examination and hematological profile is essential to arrive at a speedy diagnosis. CT and USG are useful imaging modalities of the orbit, the latter being particularly useful for follow up of the lesion.

Luxation of the globe

Emergency physicians encounter globe luxation, anterior dislocation of the eyeball beyond retracted lids, in a limited number of clinical circumstances. The authors present a case of spontaneous luxation followed by a general discussion of luxation. An understanding of the pathophysiology of various causes of luxation and the appropriate method and timing of reduction allows appropriate evaluation, treatment, and follow-up, thereby limiting patient discomfort, recurrence, and perhaps long-term visual impairment.

Graves' disease and its retroorbital aspects

Graves' disease is a common, familial, but easily treated condition caused by unique autoantibodies which act as TSH agonists. Patients with the diagnostic eye signs of Graves' disease, however, require more careful treatment than those patients with principally thyroidal involvement because destructive therapy to the thyroid gland may exacerbate the eye disease. The cause of ophthalmic eye disease appears to be "crossover specificity" by the immune system for a recurrent antigen in extraocular muscles, fibroblasts, and the thyroid gland. Treatment directed at the autoimmune response may offer the most appropriate therapy in the years to come.